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THE HYGIENE OF THE SCHOOL CHILD. 

By Lewis M. Terman, Associate Professor of 
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THE HYGIENE OF THE 
SCHOOL CHILD 



BY 



LEWIS M. TERMAN 

ASSOCIATE PROFESSOR OF EDUCATION 
LELAND STANFORD JUNIOR UNIVERSITY 




HOUGHTON MIFFLIN COMPANY 

BOSTON NEW YORK CHICAGO 



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TO 
WILLIAM H. BURNHAM 



EDITOR'S INTRODUCTION 

The editor of this series has long held that an eflS- 
cient teacher should know something as to the fun- 
damental principles of child hygiene, and that a 
school principal should, in addition, know the fun- 
damentals of schoolhouse hygiene. For schoolhouse 
hygiene we have, for some time, had a number of 
fairly serviceable texts, but of books relating to child 
development and the hygiene of instruction we have 
had but little in any form that teachers could use. 
Only recently may we be said to have come into the 
possession of such knowledge, and most of it is still 
locked up in medical and psychological journals and 
books. 

The following treatise on the "Hygiene of the School 
Child" is an attempt to digest and interpret this 
recently accumulated knowledge, and to place it in 
usable form. The book might have been called, with 
almost equal propriety, a treatise on the "Hygiene of 
Growth," dealing, as it does, so largely with the funda- 
mental facts of a child's physical development. In a 
companion volume, to be published later, the author 
will continue his interpretations by setting forth the 
relation of mental hygiene to the work of the school. 
In the two volumes, then, "The Hygiene of the School 
Child," and "The Hygiene of Instruction," will be 



viii EDITOR'S INTRODUCTION 

presented the fundamental facts of child hygiene and 
development, such as parents, teachers, and students 
of education should know. 

The time when the preparation of teachers can be 
made by a study of psychology and methods ought to 
pass. When it does it will mean that the health and 
physical welfare of a child will then be regarded as of 
as much importance as arithmetic and geography, and 
then a knowledge of the elements of child hygiene will 
be regarded as of fundamental importance in the 
training of every teacher. In many colleges and nor- 
mal schools such a change is now taking place, and it 
is for such use that this textbook has been prepared. 
Teachers in service, too, ought to find such informa- 
tion as is contained in the following pages of great 
interest to them personally, and of much usefulness to 
them in their relations with their children. 

Such an interpretation of scientific researches relat- 
ing to growing children as this book contains ought 
also to prove of much interest and value to that large 
and rapidly increasing number of parents who are 
interested in the proper rearing and education of their 
children. 

Ellwood p. Cubberley. 



PREFACE 

This work has been prepared as a textbook in school 
hygiene for the use of normal schools, colleges, and 
teachers' reading circles. 'It has been shaped by the 
conviction that the primary concern of such a text 
should be the child itself, — the hygiene of physical 
and mental growth, rather than the details of school 
architecture and school equipment. The architect and 
the engineer working alone cannot guarantee the 
healthfulness of school life. Hygienic buildings and 
equipment are necessary, but they do not go far in the 
conservation of the child. Moreover, the average 
teacher has little voice in the construction, ventilation, 
lighting, and equipment of school buildings. She must 
accept these as she finds them. But she has hourly 
opportunity, in her control of school activities, to 
observe or to violate the principles relating to the 
hygiene of physical and mental development. 

On the phases of school hygiene here treated there 
exists, in spite of many regrettable gaps, a large and 
valuable literature. Most of it, unfortunately, has 
remained hidden away in medical treatises and scien- 
tific periodicals on hygiene. The author has endeav- 
ored to summarize and interpret the best of this 
rather technical literature for the use of teachers and 
parents. 



X PREFACE 

If European investigations, particularly those of 
German writers, are quoted more often than American 
sources, this is because school hygiene as a science has 
been little cultivated in our own country. America 
does not yet have a single periodical of school hygiene; 
Germany has at least four of excellent scientific 
quality. 

It would be vain to expect that a work having the 
scope of the present volume could be kept free from 
error. Either for lack of positive investigations, or 
because of conflicting data, many of the subjects 
treated remain in dispute. In such cases, it is not 
always easy to be judicial and impartial. 

The author is indebted largely to the counsel and 
encouragement of friends for whatever merit this work 
possesses. Dr. E. B. Hoag, Specialist in Child Hygiene 
for the Minnesota State Board of Health, has fur- 
nished helpful suggestions for chapters xii to xv, 
inclusive. Dr. E. B. Huey, Assistant in Psychiatry, 
Johns Hopkins University, has given invaluable 
assistance in the preparation of the chapters on "Pre- 
ventive Mental Hygiene." Without the inspiration of 
Professor William H. Burnham, the work would not 
have been undertaken; without the encouragement 
of the editor of the series, it could not have been 
completed. 

Stanford University, 
December 18. 1913. 



CONTENTS 



, CHAPTER I 

Introduction: The Broader Relations of Educa- 
tional Hygiene 1 

School hygiene as a part of the problem of conservation. 
The cost of preventable disease. The relation of education to 
the conservation of life. Health work in the schools must 
be extended. References. 



CHAPTER II ^ 

The Physical Basis of Education . . ... . 13 

The biological perspective. Importance for education of 
such problems as those relating to growth, morbidity, rela- 
tion between mental and physical conditions, etc. Neglect 
of physical education. References. 

CHAPTER III 

The General Laws of Growth . . . . . . . 20 

Sources of data. Tables and curves of growth. Absolute 
increment and percentile increment in growth. Oscillations 
in growth. Growth rate and resistance to disease. Relation- 
ship between physical and mental growth. Relation of 
pubertal retardation to ultimate size. References. 

CHAPTER IV 

The Factors influencing Growth 32 

The internal factors: racial heredity and immediate ances- 



try. The external factors: poverty, nutrition, housing, sea- 
sonal influence, effects of school life, alcohol, drugs, etc. 
References. 



xii CONTENTS 

CHAPTER V 

Some Physiological Differences between Chil- 
dren AND Adults 47 

General differences. Circulatory system. Digestive sys- 
tern. The respiratory system. The muscular system. The 
skeletal system. The nervous system. The lack of regularity 
in growth. References. 



CHAPTER VI 

The Educational Significance of "Physiological 
Age" 61 

Distinction between chronological, anatomical, and 
physiological age. Anatomical age. Physiological age. Con- 
clusions. References. 

CHAPTER VII 

Disorders of Growth and the Hygiene of Posture 72 

Spinal curvature. Review of investigations showing fre- 
quency. Kyphosis (outward curvature). Exercises for cor- 
rection of kyphosis. Lordosis (inward curvature). Scoliosis 
(lateral curvature). Injuries produced by spinal curvature. 
Causes of spinal curvature: rickets, tuberculosis of bone, un- 
even length of legs, postural causes, etc. Table summarizing 
chief defects and their causes. References. 

CHAPTER Vni 

Malnutrition in School Children 98 

The importance of nutrition. Are many children ill- 
nourished ? Inadequate feeding as a cause of malnutrition. 
Other causes. Identifying the ill-nourished. The responsi- 
bility of the school. School feeding. Children's dietaries. 
References. 

CHAPTER IX 

Tuberculosis and the School 127 

The ravages of tuberculosis. Tuberculosis in childhood. 
Review of investigation of incidence, sources of infection. 



CONTENTS xui 

etc. Means of prevention. What the school can accomplish: 
instruction in personal hygiene, a hygienic program, play- 
grounds, school baths, seating, open-air schools, school 
medical and dental clinics, etc. References. 



CHAPTER X 

The Physiology of Ventilation 148 

Ventilation not merely a problem of engineering. The 
physiology of respiration. The part of the lungs, blood, 
heart, and muscles in the respiratory process. The mechan- 
ism of respiration. Source of injury produced by bad air. 
The chemical theory. Theory of organic poisons. Influ- 
ence of air currents, temperature, and humidity. The body's 
, heat-regulating mechanism. Healthy vasomotor action. 

CHAPTER XI 

The Teeth of School Children 167 

The problem. What examinations of children's teeth have 
disclosed. Injuries produced by defective teeth: mastica- 
tion, general poisoning, nervousness, mental alertness, 
growth, etc. Causes of dental caries. Prevention. Teaching 
of mouth hygiene. Orthodontia. Indications of dental 
defects. References. 

CHAPTER XII 

The Hygiene of the Nose and Throat . . . .197 

Relation of nose and throat to health. Enlarged tonsils. 
Adenoids. Effects of adenoids. Causes of adenoids. Sug- 
gestions for observation. Summary. References. 

CHAPTER XIII 

Defects of Hearing and the Hygiene of the Ear 221 

The prevalence of defective hearing. The importance of 
hearing for mental development. Discharging ears. The 
causes of defective hearing. The responsibility of the school. 
Directions for testing hearing. Special schools for deaf chil- 
dren. Some indications of ear defects. References. 



xiv CONTENTS 

CHAPTER XIV 

The Hygiene of Vision 245 

New demands on the eye. The mechanism of vision. 
Definition and discussion of eye conditions. Emmetropia. 
Hyperopia. Myopia. Astigmatism. Muscular deviations. ^ 
Eye-strain in relation to visual defects. Signs and symptoms 
of eye-strain. Directions for testing vision. Summary and 
conclusions. School lighting, school work, school oculists, 
etc. References. 

CHAPTER XV 

The Headaches of School Children ..... 282 
Frequency. Causes. Prevention. References. 

CHAPTER XVI 

Preventive Mental Hygiene 289 

I. The Nervous Child. 

Some nervous disorders are functional. Symptoms of 
/nervous disorders: physical, emotional, volitional, moral, 
etc. Suggestions for observation. 

CHAPTER XVII 

Preventive Mental Hygiene 299 

II. Common Neuroses op Development. 

Psychasthenia. Hysteria. Dementia prsecox. Chorea. 
Tics, habit-spasms, etc. Epileptic school children. 

CHAPTER XVIII 

Preventive Mental Hygiene 318 

III. The Education of Nervous Children. 

Faulty education as related to nervous disorders. The 
value of social experience. Methods of discipline. Training 
in self-reliance and self-control. Cultivating habits of 
efficiency. The sanifying effects of work. Danger of shock. 
Special schools for nervous children. Selected references. 



CONTENTS XV 

CHAPTER XIX 

Speech Defects and the Hygiene of the Voice 335 

Stuttering as a handicap. The incidence of speech defects. 
Lisping. Stuttering. Causes of stuttering. The treatment 
of stuttering children in special schools. Method used. The 
prevention of speech defects. Suggestions for observing 
speech defects . References . 

CHAPTER XX 

The Sleep of School Children 362 

The amount of sleep needed. Theoretical norms. Investi- 
gations of children's sleep : Bernhard, Ravenhill, Terman and 
Hocking. The relation of sleep to intelligence, school success, 
"nervous traits," etc. Sleep of the feeble-minded. Explana- 
tions for lack of correlation between hours of sleep and men- 
tal efficiency. The conditions of children's sleep. Exterifc,! 
conditions. Internal conditions. Teaching children to sleep. 
Suggestions for a sleep survey of school children. References. 

CHAPTER XXI 

Some Evil Effects of School Life 381 

The problem. The school as a cause of morbidity. The 
effects of school life upon growth. Effects upon appetite, 
nutrition, and the composition of the blood. The formal 
examination. Effects of school postures upon respiration. 
Psychopathological effects of school life. The annual accu- 
mulation of fatigue. Types of children likely to be injured 
by the work and environment of the school. References. 

Suggestions for a Teacher's Private Library on 
the Hygiene of Physical and Mental Growth 408 

Glossary 410 

Index 413 



LIST OF ILLUSTRATIONS 

Facing 
Dr. Rotch's radiographs of the hands of children . . .62, 63 
Round shoulders, lateral curvature, and "wing" shoulder 

blades in forward shoulders 76 

A very serviceable test for posture 94 

The phenomena of dental caries and the development of an 

abscess 176 

The replacing of the temporary teeth 188 

The results of orthodontia 188 

The primary incision for separating the hypertrophied tonsil 

from its attachments 212 

Before and after the removal of adenoids 213 



LIST OF FIGURES AND CHARTS 

1. Growth in height and weight . . . . . .23 

2. Annual percentile increment of growth in weight and height 24 

3. How the proportions of a new-born child differ from those 

of the adult 47 

4. Increase in lung capacity 52 

5. Increase in strength of grip for right hand 54 

6. Percentage of each pubescence sub-group for each half-year 
group^^ .64 

7. A "C" curve resulting from uneven extremities ... 80 

8. One-sided position from standing on one foot ... 81 

9. The correct position for recitation or prolonged standing . 81 

10. Desk too high 82 

11. The progress of an "S" curve under treatment for three 
years 85 

12. Flat-foot . 87 

13. One of the first signs of flat-foot 88 

14. Imprint of (1) arched foot, and (2) flat-foot .... 89 

15. A passage blocked by adenoids 208 

16. A clear passage to the lungs 209 

17. Emmetropic or normal eye . . 247 

18. Hypermetropic or long-sighted eye 248 

19. Diagram to illustrate accommodation 248 

20. Myopic or short-sighted eye 249 

21. Curve of fatigue for eye accommodation 266 



LIST OF FIGURES AND CHARTS xvii 

22. Percentage of children lisping or stuttering in the first six 
grades 339 

23. Line indicating the monotony of the stutterer's voice . . 356 

24. Line indicating how the normal voice should rise and fall . 356 

25. Amount of sleep children actually receive compared to 
Duke's theoretical standard 367 

26. Extremes in amount of sleep secured at different ages . . 368 

27. Sleep of mentally defective children compared with that of 
normals 372 

28. Increase of morbidity with age among 1900 girls in German 
middle schools 383 

29. Increase of morbidity with age among 500 girls in a German 
secondary school 384 

30. Percentage of certain defects according to grade for pupils 

in the secondary schools of Russia 386 

31. Effect of school entrance on the size of children's spontane- 
ously controlled drawings 399 

32. Annual curve of fatigue in school children .... 401 

33. Curve of mental fatigue during the school year . , . 402 



THE HYGIENE OF THE 
SCHOOL CHILD 

CHAPTER I 

INTRODUCTION: THE BROADER RELATIONS OF 
EDUCATIONAL HYGIENE 

School hygiene as a part of the problem of conservation 

The rapid development of health work in the schools 
during the last two decades is not to be regarded merely 
as an educational reform, but rather as tke corol- 
lary of a widespread realization of the importance of 
preventive measures in the conservation of natural and 
human resources. The prevention of waste has be- 
come, in fact, the dominant issue of our entire political, 
industrial, and educational situation. 

In many ways society is enlarging its interest in the 
individual. The laissez-faire policy of a few genera- 
tions ago is being replaced by humanitarian foresight, 
restrictive measures, and large cooperative social un- 
dertakings. We are rapidly becoming conscious of hith- 
erto unsuspected power to shape human destinies 
and are no longer willing to remain the passive play- 
thing of uncontrolled social and material forces. The 
evolution concept is doing its work. Having at last 
consented to look at ourselves from the biological point 
of view, we proceed to harness the biological and social 
forces which will make for the development of a hap- 



2 THE HYGIENE OF THE SCHOOL CHILD 

pier, healthier, and better race. Evolution has made us 
conscious of a future, has shown us how to attain it, 
and most important of all, has made that future a 
matter for our practical concern. Our highest boast is 
coming to be that we, the present generation, are living 
not only for ourselves, but also for the generations that 
are to follow. 

Of course it must be admitted that Utopias for the 
betterment of human conditions are not a new inven- 
tion. The imagination, fortunately, has always found 
satisfaction in the fanciful creation of an ideal social 
structure. But previous to recent governmental and 
scientific advances such dreams were but empty fan- 
cies, incapable of realization. The forces which make 
or mar the destinies of man were far less amenable to 
control than is the case to-day. At present the develop- 
ment of industrial processes and the various sciences of 
conservation give us hope that at least the worst con- 
ditions of poverty can be done away with; the remark- 
able progress of medicine demonstrates that many of 
man's physical ills can be overcome and many others 
eliminated by preventive means; and finally, the laws 
of heredity, when fully known and heeded, are capable 
of raising the average of mental, moral, and physical 
endowment well above where it now stands. Every 
civilized nation is becoming acutely conscious of the 
necessity of utilizing all possible means for conserving 
these vital resources and of adding to them. 

Among the greatest of these influences is medicine, 
preventive and curative. Such diseases as smallpox. 



INTRODUCTION 3 

tuberculosis, diphtheria, malaria, yellow fever, typhoid, 
bubonic plague, and cerebro-spinal meningitis have 
rapidly yielded up secrets which make it possible, for 
the most part, either to prevent the disease or to 
cure it. The technique of diagnosis and of surgery has 
been refined beyond the boldest prophecy of a few 
decades ago. With the growth of our understanding of 
disease there goes pari passu a keener sensitiveness to 
the presence of physical imperfections. We now know 
that an amazing amount of physical defectiveness has 
always stared us in the face without our recognition. 
Among the masses of people, however, there remains 
a vast amount of ignorance with regard to matters oi' 
health and disease. The daring researches of a few 
score bacteriologists are more than offset by the 
thousands of people who still use liverwort for jaundice 
because of the fancied resemblance of its leaf to the 
human liver; by the tens of thousands who treat infec- 
tious diseases by suggestion; by the millions who 
spend hard-earned money for patented consumption- 
cures. Popular notions regarding personal hygiene are 
little better than a seething welter of ignorance and 
superstition, not all of which is confined to those who 
are confessedly uneducated. 

The cost of preventable disease 

The cost of this ignorance in money, sickness, death, 
and grief is stupendous. Basing his estimate upon sta- 
tistics of mortality for ninety different diseases and 
accepting the expert opinion of numerous medical 



4 THE HYGIENE OF THE SCHOOL CHILD 

specialists as to the ratio of preventability for these 
diseases, Professor Irving Fisher has reckoned that the 
general adoption of a few well-established hygienic 
principles would add fifteen years to the average span 
of human life. For the most part these fifteen lost years 
would be years of economic productivity. It is evident 
that every premature death entails an economic loss 
upon society, varying according to the age of the per- 
son dying. It is computed that the newborn child has 
an average money value of at least $95. The value 
increases to $960 by five years, to $4000 by twenty 
years, and drops again to $2900 by fifty years. The 
minimum average loss to society from each postpon- 
able death has been elaborately figured at $1700. Of 
the 1,500,000 deaths in the United States each year the 
combined opinion of the best medical authorities re- 
gards at least 42 per cent to be postponable, or 600,000. 
The annual loss to the country from this cause is there- 
fore $1700 X 600,000, or $1,070,000,000.' 

Nor does this complete the story of waste. For each 
unnecessary death there are several cases of unneces- 
sary illness, the total cost of which, counting medical 
attendance and wages lost, amounts to nearly $1,000,- 
000,000 more. The Great White Plague alone involves 
an annual loss of not less than $500,000,000. Typhoid 
fever costs us some $200,000,000; malaria, $100,000,- 
000, besides its indirect injury in undermining health; 
and the hookworm disease an equal amount. It is esti- 
mated that there are from 2,000,000 to 3,000,000 cases 
of malaria in the United States each year, and that 



INTRODUCTION 5 

about 2,000,000 persons suffer from the hookworm 
disease. The loss of economic efficiency from alcohol- 
ism, vicious habits, undue fatigue, minor ailments, and 
lack of expert direction of the human machine can only 
be vaguely guessed at, but it is probably greater than 
that from all the other causes enumerated. Apart from 
this, however, we suffer an aggregate calculable loss 
from preventable illness and death of about $2,000,- 
000,000 per year, or over four times the total ex- 
penditures for public education. This is equal, at 4 per 
cent, to the annual interest on $50,000,000,000. 

The meaning of such figures can be made more clear 
by a comparison with other values. The total physical 
wealth of the United States has been estimated at 
about $110,000,000,000, and the value of our annual 
agricultural products at about $9,000,000,000. Our 
railways are worth about $17,000,000,000, and the 
annual output of our manufactures about $15,000,000,- 
000. Our vital assets, however, are by far the most 
important of all. Adopting Professor Irving Fisher's 
figure of $2900 as the average value of one individual 
to society, the total economic value of our 90,000,000 
inhabitants reaches the sum of $250,000,000,000. This 
is almost exactly 1000 times the value of our hogs, for 
the conservation of which the nation expends more 
money than it does for the conservation of its children. 

But statements of economic loss do not fully repre- 
sent the importance of health conservation. Waste of 
life or health involves grief and moral suffering which 
cannot be measured in gold. Infant mortality illus- 



6 THE HYGIENE OF THE SCHOOL CHILD 

trates the point. In the most enlightened countries 
from 15 to 20 per cent of the infants die in the first year 
of life. In Russia, Austria, southern Italy, and even in 
limited districts of England and Massachusetts infant 
mortality reaches 30 to 40 per cent. Although the 
economic significance of infant mortality is much less 
than that of tuberculosis, morally the two problems 
are of nearly equal importance. 

The relation of education to the conservation of life 

In the work of conserving national vitality we can- 
not rely altogether upon the progress of medical science 
and upon reforms of public health administration. 
These measures must be supplemented by a never- 
ending campaign for the enlightenment of the young 
in matters of personal and social hygiene. The practice 
of hygiene in the average home follows far in the rear of 
medical discoveries. 

Infant mortality again offers an apt illustration. 
Bacteriology teaches that from one half to two thirds 
of infant deaths are due to the neglect of a few simple, 
hygienic precautions. In spite of this fact, statistics 
demonstrate that this needless slaughter has been but 
little affected by the advances of preventive medicine. 
It will continue little abated unless the new generation 
is educated to a different hygienic viewpoint. In the 
prevention of infant mortality, as well as in the con- 
servation of vitality in general, no other agency is 
capable of contributing as much as the public school. 

Numerous conditions peculiar to modern life have 



INTRODUCTION 7 

forcibly called our attention to the problems of hygiene. 
Among these are the industrial changes of the last 
century and the consequent urbanization of the popu- 
lation. In 1790, but 3.4 per cent of the population 
dwelt in cities of 8000 or over. By 1900, this had risen 
to 33.1 percent. The growth of cities has greatly com- 
plicated the problems relating to food, housing, con- 
tagious disease, etc. Industrial methods have multi- 
plied dangerous employments, have specialized in a 
most unhealthful way the physical activities involved 
in work, and have often favored the most wearisome 
and monotonous occupation of the mind. 

So radical are the adjustments which civilieation 
demands in our habits of living that the factors which 
controlled and directed the evolution of the human 
body have in large part become inoperative. Our 
modes of sedentary life tend less and less to bring into 
play the physical traits which were of greatest value in 
the primitive struggle for existence. Instead, excessive 
burdens are laid upon functions and organs never 
intended by nature to endure them. 

If only the intentions of nature were respected during 
the period of growth and development the problem 
would by no means be so serious. The youth who has 
been brought into possession of his full psycho-physical 
inheritance would be in a position to conserve this 
inheritance in the face of great odds. This we do not 
permit. The healthful play of children has ever become 
more difficult. The introduction of universal educa- 
tion has changed the whole life of the child from one 



8 THE HYGIENE OF THE SCHOOL CHILD 

of active to one of sedentary occupation. As stated by 
Gulick, "so extensive a readjustment of the life habits 
of the young of a species has never before been at- 
tempted." 

We do not yet know what the result of this experi- 
ment will be, but it is unreasonable to suppose that 
man presents any exception to the biological law that 
the ultimate survival of an organism is threatened 
whenever it is subjected to conditions of environment 
widely different from those which directed its evolu- 
tion. We have taken the child out of its natural habi- 
tat of open air, freedom, and sunshine, and for nearly 
half his waking hours we are subjecting him to an 
unnatural regimen, one which disturbs all the vital 
functions of secretion, excretion, digestion, circulation, 
respiration, and nutrition. 

If all children were perfectly healthy when received 
into the school, they might be expected to make the 
adjustment with little or no permanent injury. But 
the school does not deal chiefly with healthy children. 
Medical inspection in scores of American cities demon- 
strates that as a rule not more than one third of our 
school children are free from physical defects preju- 
dicial to health. Of the 20,000,000 children enrolled in 
our schools some 14,000,000 are more or less handi- 
capped in this way. 

Not far from 2,000,000 (10 per cent) are suffering 
from a grave form of malnutrition; 10,000,000 (50 per 
cent) have enough defective teeth to interfere seriously 
with health; at least 2,000,000 (10 per cent) suffer from 



INTRODUCTION 9 

obstructed breathing due to adenoids or enlarged ton- 
sils; probably 2,000,000 (10 per cent) have enlarged 
cervical glands which need attention, many of these 
being tuberculous; at least 10,000,000 (50 per cent) are, 
or have been, infected with tuberculosis, of whom 
about 2,000,000 (10 per cent) will later succumb to the 
disease; 4,000,000 (20 per cent) have defective vision; 
over 1,000,000 (5 per cent) have defective hearing; 
about 1,000,000 (5 per cent) have spinal curvature or 
some other deformity likely to interfere with health; 
not far from 500,000 (2^ per cent) have organic heart 
disease; and at least 1,000,000 (5 per cent) are predis- 
posed to some form of serious nervous disorder. 

Health work in the schools must he extended 

The fact that the school doctor has been called in 
to examine and advise does not signify that the gravity 
of the situation has been apprehended. Teachers have 
simply found physical defects an impediment to the 
pupil's school progress and desire their removal. The 
school doctor spends some three to six minutes in the 
examination of each pupil, looking only for the gross 
and external symptoms of defectiveness. Having usu- 
ally the point of view of the physician, his search is for 
disease. His training has not always fitted him to dis- 
cover incipient deviations from the normal or even to 
see the necessity of doing so. 

Our plea is for a broader conception of the functions 
and scope of educational hygiene. The usual attention 
given to heating, lighting, ventilation, and gross physi- 



10 THE HYGIENE OF THE SCHOOL CHILD 

cal defectiveness is but the merest beginning. The 
school instead of causing sickness and deformity must 
be made to preserve the child from all kinds of mor- 
bidity, repair his existent deformities, combat his 
unfavorable heredity and the bad conditions of his 
environment; in a word, fortify his constitution and 
render him physically and mentally fit for the struggles 
of life. 

The greatest problem of conservation relates not to 
forests or mines, but to national vitality, and to con- 
serve the latter we must begin by conserving the child. 
We are hampered, however, by the lack of positive 
knowledge of the influences which mold a child's physi- 
cal and mental development. Many of the questions 
relating to this problem can never be answered until 
they have been attacked on a broad scale by system- 
atic and scientific methods of research. To secure 
proper scope for such research, the schools must be 
thrown open to it; to insure adequate support, it must 
be made a public undertaking.^ 

No other agency compares with the school in the 
opportunities offered for contributing to the health of 
the succeeding generation. We cannot legislate desir- 
able habits of living into men and women, but we may 
be able to mold after our ideals the hygienic habits of 
the child. 

The most characteristic tendency of present-day 
education is its progressive socialization, the increas- 

1 For a list of unsolved problems in child hygiene see reference 22, 
at end of this chapter. 



INTRODUCTION 11 

ing extent to which society is utiHzing the school as an 
instrument for the accomplishment of its ends. We are 
coming to believe that it is legitimate to levy upon the 
school for any contribution it is capable of making to 
human welfare. This social conception of education is 
quite familiar. Only let us extend its application to all 
fields of personal and social hygiene and the school will 
help to deliver us from a burden which is more oppres- 
sive than the burden of militarism; for physical ineflS- 
ciency, sickness, and premature deaths are costing us 
as much as all our crime and as much as a good-sized 
perpetual war besides. 

Apart from such considerations as the above it is not 
possible to understand or evaluate the modern crusade 
for medical and hygienic supervision of schools. It 
began as a reflection of the popular interest in matters 
of health; it will end by becoming the most effective 
and convenient instrument for the attainment of a 
higher national vitality. 

REFERENCES 

{References of greatest value for the chapter in question are marked 
with a star.) 

*1. W. H. Allen: "A Broader Motive for School Hygiene." Atlan- 
tic Monthly, June, 1908. 

*2. W. H. Burnham: "The Problems of Child Hygiene." Ped. 

Sem., 1912, pp. 395-402. 
3. Dr. Myrtelle Canavan: "Medical Data from the Examination 
of 2333 Supposedly Normal Women." Proc. 6th Cong. Am. 
Sch. Hyg. Assoc, 1912, pp. 76-91. 

*4. Elsa Denison: Helping School Children. 1912, pp. 352. 

*5. Norman Ditman: Education and Preventive Medicine. 1911, 
pp. 73. 



U THE HYGIENE OF THE SCHOOL CHILD 

*6. Sigmund Engel: The Elements of Child Protection. London, 

1912, pp. 276. Translated by Eden Paul. 
*7. Irving Fisher: "Report on National Vitality." 1909, pp. 138. 

Bull. No. 30 of Com. of 100 on National Health. 
*8. Sir John E. Gorst: The Children of the Nation. 1906, pp. 297. 
9. Hastings W. Hart, et al: Preventive Treatment of Neglected 
Children. 1910, pp. 419. 
*10. Heller, Schiller u. Taube: Enzyklopddisches Handbuch des. 
Kinder schutzes u. der JugendfiXrsorge. Bande i-ii. Leipzig, 1911'. 
*11. Dr. A. H. Hogarth: The Medical Inspection of Schools. 1909, 
pp. 360. (Chapters v to viii.) 

12. Arthur Holmes: The Conservation of the Child. 1912, pp. 345. 

13. Dr. Woods Hutchinson: Preventable Diseases. 1909, pp. 442. 
*14. J. Johnson: Wastage of Child Life. 1909, pp. 381. 

15. G. B. Mangold: Child Problems. 1910, pp. 381. (Especially 
pp. 1-158.) 

16. Earl Mayo: "The Problem of National Health." The OuilooJc, 
December 7, 1912, pp. 464-472. 

*17. Benjamin Moore: The Dawn of the Health Age. Liverpool, 

1910, pp. 204. 
*18. George Newman: Infant Mortality. 1907, pp. 356. 
19. Dr. Max Schlapp: " Our Perilous Waste of Vitality." The Out- 
look, April 6, 1912. 
*20. John Spargo: The Bitter Cry of the Children. 1906, pp. 336. 

21. Harold Spender: "A National Health Charter." Contemporary 
Review, June, 1911. 

22. Lewis M. Terman: "Professional Training for Child Hygiene." 
Pop. Sci. Mo., 1912, pp. 289-97. 

23. J.M.TyleT-.Grovyth and Education. 1907, pp. 297. (Chapter!.) 

24. J. E. W. Wallin: "Aspects of Infant and Child Orthogenics." 
The Psych. Clinic, 1912, pp. 153-72. 

25. T. D. Wood: "Health and Education." Ninth Year Book, 
National Soc. for Study of Education, 1910, pp. 113. 

26. Proc. of Conference on the Conservation of School Children. 
Published by the American Academy of Medicine. 1912, pp. 
293. 

*27. The Public Health Movement. Published by the Am. Acad, of 

Polit. and Soc. Sci., 1911, pp. 298. 
*28. Vol. Ill of Proc. of the Fifteenth International Cong, in Hyg. 

and Demog., 1913, pp. 486. 



CHAPTER II 

THE PHYSICAL BASIS OF EDUCATION 

The biological perspective 

It is necessary for us as teachers to take the biological 
point of view in all our thinking and to seek our edu- 
cational philosophy in the laws of growth. The task of 
molding human lives is one which can be accomplished 
only by an appeal to those biological processes which 
are common alike to animals and to man. Fo|^ in the 
strictest sense man is as much a natural product of 
evolutionary laws as are his brothers of the forest. His 
biological equipment is in general the same; the num- 
ber and distribution of his parts, the individual tissues 
even, and to no small extent the physiological function- 
ing of all his organs. He is subject to many of the same 
diseases and is tormented by the same parasites. Be- 
cause man's nervous system is built upon the same 
general plan as that of the other higher mammals, his 
mental equipment differs from theirs more in degree 
than in kind. His senses are the same, he is moved by 
similar instincts and emotions, and his intellect em- 
braces no "faculty " which is not present in cruder form 
in the mental life of other animals. He is obedient to 
the same laws of heredity, and is therefore capable oil 
the one hand of improvement by eugenics, and on the 
other hand subject to racial degeneration. 



14 THE HYGIENE OF THE SCHOOL CHH^D 

For the understanding of childhood, especially, the 
biological perspective is absolutely essential. It is then 
that natural instincts, primitive modes of mentation, 
and growth influences of remote origin are most in evi- 
dence. If the lengthened period of immaturity in man 
is not conceived of in its evolutionary setting, education 
cannot set a rational goal or choose aright the processes 
by which the goal is to be attained. It is our tendency 
to view the child as a being set apart from the rest of 
organic creation which causes us to neglect the physi- 
cal limits and determinants of human possibilities, to 
teach children as though they were disembodied spirits, 
to judge the child by adult standards, to forget that 
the best of education is but wisely directed growth. 
Besides a general biological orientation, such as might 
be expected from a well-planned course dealing with 
man's place in nature, every teacher should have con- 
siderable acquaintance with the problems and princi- 
ples mentioned in the following paragraphs. 

(a) The order of physiological maturity. Every part 
of the body has its own order of development and 
its own critical periods, the nervous, muscular, circu- 
latory, respiratory, and digestive systems in particu- 
lar. Education must follow this order, measuring its 
demands and requirements by the child's stage of 
maturity. Many an educational problem is solved by 
growth alone. 

(6) The main factors in mortality and morbidity. The 
teacher should know what diseases are prevalent among 
children at various stages of development. The degree 



THE PHYSICAL BASIS OF EDUCATION 15 

of resistance to disease determines in large measure the 
kind of education the child should have. Instruction 
can wait, as Dr. Burnham reminds us, but the demands 
of health are imperative. Health first, then education, 
should be the motto. We have hardly begun to appre- 
ciate the real significance of a clean bill of health and 
heredity. We make no inquiries of this sort regarding 
the new pupil, but ask only his marks in the subjects of 
instruction. It is necessary to know something about 
all the physical abnormalities commonly met with 
among school children, defects of eyes, ears, nose and 
throat, teeth, spinal deformity, malnutrition, anaemia, 
nervous states, etc. This knowledge should include for 
each defect something of its causes, its effects upon 
general health, its symptoms, and the appropriate 
methods of treatment, both educational and medical. 
Too often tuberculosis steals the child or spinal curva- 
ture deforms him while we wrangle over rival methods 
of teaching him geography or grammar or spelling. 

(c) The relation between mental and physical condi- 
tions. The nervous system is so intimately concerned 
in every act of knowing, feeling, and willing that, if our 
knowledge were only greater, education could be de- 
scribed in purely neurological terms. When we know 
more about the physical basis of mental life we shall 
quit teaching grammar to feeble-minded children who 
cannot learn to count money. We shall appreciate the 
wisdom of the old proverb which tells us that "it is 
impossible to make a silk purse out of a sow's ear.'* 
We shall understand that the difference of some bil- 



16 THE HYGIENE OF THE SCHOOL CHILD 

lions of brain cells between the imbecile and the genius 
is a difference which education cannot wipe out or 
afford to ignore. We shall not expect to find normal 
instincts, emotions, intelligence, or conduct in children 
who are unhealthy or disinclined to play. We shall 
understand that fatigue and work have their strict 
physiological determinants dependent upon bodily 
rhythms, the disintegration of cell tissue, the accumu- 
lation of toxins, processes of waste elimination, repair, 
and the like. We shall think even of criminality, tru- 
ancy, inattention, laziness, etc., in terms of a possible 
physical cause. 

{d) The dynamic aspects of education. The education 
of the mind is closely related to the activity of the 
muscles. In the race and in the individual, mind and 
muscle develop together. The human hand and the 
human intellect would each have been impossible with- 
out the other. The low-grade feeble-minded are always 
deficient in motor power and in delicacy of coordina- 
tions. Their cerebral activities are as clumsy as their 
manual, and the former can be improved by the 
education of the latter. The motor element is present 
in all our thinking. Every school subject has its dy- 
namic aspect. We cannot truly possess knowledge until 
we have used it. A thing is what we can use it for; our 
idea of it is determined by our motor attitude toward 
it. One's whole personality is a bundle of accomplish- 
ments and possible accomplishments. Thinking, bio- 
logically speaking, is never its own end, but a means 
toward adaptation, which is essentially motor. 



THE PHYSICAL BASIS OF EDUCATION 17 

When we have appHed this biological point of view 
in our educational psychology we shall less often exalt 
knowing above doing. Much of the time we now give 
to book instruction will be replaced by opportunities 
for activity. The educational aim will lose its bifur- 
cated aspect and the child will be recognized as an 
organic unity. The child's mind will cease to be the 
enemy of his body, and the welfare of each will be 
sought in the maximum culture of the other. 

Knowledge without health cannot profit us. "Non 
scolse, sed vitse," interpreted by hygiene, means that 
success in life depends as much on the integi^ty of the 
energy-getting processes as on the accumulation of 
knowledge, and that the school dare not confine its 
work to the latter. Emerson is literally correct when 
he tells us that the strong heart helps us to resist 
temptation. So do healthy muscles and a sound 
digestion. To fill the child's blood with four and a half 
million red corpuscles per cubic millimeter and to 
enrich it with the oxygen-carrying haemoglobin falls 
as much within the legitimate field of education as 
instruction in the "Three R's." 

A system of education like our own, giving such a 
disproportionate amount of training to the thinking 
activities, would have seemed preposterous to the 
Greeks or Romans. Their ideal of "a sound mind in a 
sound body " needed only the scientific basis of hygiene 
and medicine to make their scheme of education the 
best the world has seen, social and industrial condi- 



18 THE HYGIENE OF THE SCHOOL CHILD 

tions considered. The religion of medieval Europe 
taught that the salvation of the soul was dependent 
upon the debasement of the body. Europe learned the 
lesson only too well. A frank exposition of the uni- 
versal neglect of personal and public hygiene in the 
Middle Ages would bar this book from the United 
States mails. 

Unfortunately, modern education has been influ- 
enced in its attitude toward the body by medieval 
rather than by Greek and Roman ideals. Physical 
education has played an insignificant part in modern 
educational theory and still less in educational prac- 
tice. Our schools are still what the Germans call Lern- 
schule. The latest textbooks on the "principles of 
education " all but ignore the subject, and no compre- 
hensive philosophy of physical education has yet been 
attempted. In actual practice the subject will not 
receive the attention it deserves until the educational 
machinery for its control is as complete and as well 
organized as our best system for the supervision of 
instruction. 

REFERENCES 

1. W. C. Bagley: The Educative Process, pp. 1-22. 

2. Luther BurbaBk: The Training of the Human Plant. 

3. N. M. Butler: The Meaning of Education, pp. 3-17. 
*4. John Fiske: The Meaning of Infancy. 

5. E. N- Henderson: A Textbook of the Principles of Education^ 
1910. (Chapters ii and iii.) 

6. CHeTter: Biological Aspects of Human Problems. 1912. 

7. Harold Home: The Philosophy of Education, pp. 18-56. 

8. M. V. O'Shea: Education as Adjustment, pp. 44-51. 

*9. M, V. O'Shea: Dynamic Factors in Education, chapters iv, v, 

and VI. 
10, G. E. Partridge: The Genetic Philosophy of Education, pp. 3-90. 



THE PHYSICAL BASIS OF EDUCATION 19 

(An exposition of the views of G. Stanley Hall on the philo- 
sophical, biological, and psychological foundations of educa- 
tion.) 
11. W. C. Ruediger: The Principles of Education, chap. ii. 

*12. Herbert Spencer: Education. (Especially the chapter on physi- 
cal education.) 

*13. J. M. Tyler: Growth and Education, chap. ii. 



CHAPTER III 

THE GENERAL LAWS OF GROWTH 

Sources of data 

A COMPLETE census of the physical conditions of a 
nation's children, planned with special reference to dis- 
covering the laws of growth and their modification by 
various environmental and social influences, would be 
beyond comparison more valuable than all the censuses 
of property and population ever taken. But no nation 
has ever taken an inventory of its chief resource, the 
raw material for the new generation. Scattered inves- 
tigations have been made, however, in nearly all coun- 
tries, involving altogether measurements of more than 
150,000 children of both sexes and different ages. Not 
all of these have been taken with uniform procedure or 
with sufficient precautions to guard against error, nor 
has the statistical treatment of the data always been 
satisfactory. 

To review in detail even the most important anthro- 
pometrical studies of growth would carry us beyond 
the scope of the present chapter, the purpose of which is 
limited to the presentation of the most important laws 
of growth.^ Growth statistics are likely to be mislead- 

* The most important of these studies are those of Porter, Peck- 
ham, Bowditch, West, Boas, and MacDonald, in America; Roberts, 
in England; Hertel and Malling-Hansen, in Denmark; Geissler, 



THE GENERAL LAWS OF GROWTH 21 

ing unless used with extreme caution. Measurements, 
of height and weight, especially, are of doubtful value 
as guides for the hygiene of physical development. In 
the first place, these are not simple phenomena, but 
complex resultants of many factors, the individual 
significance of which is in no way elucidated by the nu- 
merous tables of established "norms," Our knowledge 
of growth needs to be much more specific than this and 
should include exact information relating to the devel- 
opment of all the organs, the significant changes in 
their mode of functioning from birth to senescence, 
the important abnormalities of development, and the 
degree of resistance to various diseases resultii|g from 
the ensemble of physical traits of each age. In the 
second place, the growth status of the individual can 
never be evaluated by a table of norms computed 
from growth averages. Each individual is a law unto 
himself. A school child may be several inches shorter 
and many pounds lighter than the average for children 
of his age, race, and sex, while fully reaching the stand- 
ard which nature set for him. Nor can we set any lim- 
its above and below which abnormality is reliably in- 
dicated in the individual child. Measurements of size 
can give little clue to the normality of the processes 
within. Growth averages are, however, of value as 

Schmid-Monnard, Engelsperger, and Lucy Hoesch-Ernst, in Ger- 
many; Chaumet and Binet, in France; Zak and Viazemsky, in Russia. 
More detailed studies of the phenomena of growth will be found in 
the admirable summaries of Burk, MacDonald, and Hoesch-Ernst, 
while the extensive treatment of the subject in Hall's Adolescence 
is unequaled for suggestive interpretation. 



22 THE HYGIENE OF THE SCHOOL CHILD 

norms for comparative study of masses of children 
different in age, sex, race, social environment, etc. 

Of the scores of available curves and tables which 
might be presented for this purpose, those which fol- 
low are the most reliable for use with American-born 
children. 



TABLE 1 



V 


cn 




Boys 








Girls 




J2 V 


tS fl 
















S ^ 


° o 








1? 










Average 


Absolute 


Perc'tage 


Average 


Absolute 


Perc'tage 




for each 


annual 


annual 


a *^ 

3 ^ 


for each 


annual 


annual 




^-o 


year: 


increase: 


increase: 


12:^3 


year: 


increase: 


increase: 


'-' 


inches 


inches 


per cent 


*^ O 


inches 


inches 


per cent 


5h 


1535 


41.7 


2.2 


6.3 


1260 


41.3 


2.0 


4.8 


if 6h 


3975 


43.9 


2.1 


4.8 


3618 


43.3 


2.4 


5.5 


1 


5379 


46.0 


2.8 


6.1 


4913 


45.7 


2.0 


4.4 


8i 


5633 


48.8 


1.2 


2.5 


5289 


47.7 


2.0 


4.2 


Qh 


5531 


60.0 


1.9 


3.8 


5132 


49.7 


2.0 


4.0 


101 


5151 


51.9 


1.7 


3.3 


4827 


51.7 


2.1 


4.1 


111 


4759 


63.6 


1.8 


3.4 


4507 


63.8 


2.3 


4.3 


121 


4205 


55.4 


2.1 


3.8 


4187 


66.1 


2.4 


4.3 


131 


3573 


67.5 


2.5 


4.3 


3411 


58.5 


1.9 


3.2 


14§ 


2518 


60,0 


2.9 


4.8 


2537 


60.4 


1.2 


2.0 


15§ 


1481 


62.9 


2.0 


3.2 


1656 


61.6 


0.6 


1.0 


161 


753 


64.9 


1.6 


2.6 


1171 


62.2 


0.5 


0.8 . 


171 


429 


66.5 


0.9 


1.4 


790 


62.7 




r 


18i 


229 


67.4 















Showing average American height, mathematically calculated, by Dr. 
Franz Boas, from measurements of 45,151 boys and 43,298 girls in the 
cities of Boston, St. Louis, Milwaukee, Worcester, Toronto, and Oakland; 
also the absolute and the percentage annual increment of same. 



THE GENERAL LAWS OF GROWTH 23 
TABLE 2 





Boys 


Girls 


Age 


Average 
for each 

age: 
pounds 


Absolute 
annual 
increase: 
pounds 


Annual 
increase: 
per cent 


Average 
for each 

age: 
pounds 


Absolute 
annual 

increase: 
pounds 


Annual 
increase: 
per cent 


6h 
7i 
8^ 
9h 

12i 

I3i 

m 


45.2 
49.5 
54.5 
59.6 
65.4 
70.7 
76.9 
84.8 
95.2 
107.4 
121.0 


'4.3 

5.0 

5.1 

5.8 

6.3 

6.2 

7.9 

10.4 

12.2 

13.6 


" 9.5 

10.1 

9.3 

9,7 

8.1 

8.7 

10.3 

12.3 

12.8 

12.7 


43.4 

47.7 

52.5 

57.4 

62.9 

69.5 

78.7 

88.7 

98.3 

106.7 

112.3 

115.4 

114.9 


'4;3 
4.8 
4.9 
5.5 
6.6 
9.2 

10.0 
9.6 
8.4 
5.6 
3.1 


' 9.9 
10.0 

9.3 

9.6 
10.5 
13.2 
12.7 
11.9 

8.5 

6.2 

2.8 

« 



Showing the average American weight mathematically calculated, by M. de 
Perrot, from the data of about 68,000 children in the cities of Boston, St. 
Louis, and Milwaukee; also absolute and percentage annual increases of same. 

The averages in the above tables are graphically 
represented in the curves given in figures 1 and 2. 
Among the most 

Inches' 

important facts to 68 
be gleaned from 
measurements of 
growth are the fol- 
lowing: — 

(1) Absolute in- 
crement and per- 
centile increment. 
The curves showing 

these are quite un- Ago 5 6 7 8.9 101112 13U1516 it is 
like. The former fig. 1 

refers to the actual showing Growth in Height and Weight 




40 



M THE HYGIENE OF THE SCHOOL CHILD 



% 

13 
12 
11 

10 











































c 




/ 






















if 




.. 


A 
















^^ 






^/' 


c^7 


\ 














^ 


-^N.^ 


\« 


^ 




^ 


/ 




\ 

\ 












W! 


IGt 


iT 




V 


y 






'^ 




































































■^\/ 


A 


























<J'. 


k\ 






3\B 


L.S_ 


-^! 




N 
















\ 


/^ 




^ 


,-«-^ 


r 




\^ 














V 










\ 


N^ 




k 








H 


;iG 


HT 


















\ 































.5678 910.1112131415161718 
FIG. 2 



gain in pounds or inches; the latter is the ratio (ex- 
pressed in percentage) between 'the gain in a given 

period of time and 
the total weight or 
height. Although 
growth is usually 
described in terms 
of absolute incre- 
ment, percentile 
increment would 
be less misleading. 
Measured by per- 
centile increment, 
growth before birth 

Showing Annual Percentile Increment of Growth is almost infinitely 

in Weight and Height 

more rapid than it 
ever is again. In the nine months preceding birth, 
weight increases nearly a billion-fold; in all the years 
after birth only about twenty-fold. As expressed by 
Minot (20), we have already lost at the time of birth 
98 per cent of our growth "momentum.'* Most of that 
which remains is lost within the first three years. Both 
quantitative and qualitative changes succeed each other 
with ever increasing slowness, like the construction of 
a wall, which first proceeds rapidly and becomes more 
and more retarded as the distance from the ground 
increases. 

Thus we may be said to approach senescence most 
rapidly in the early years and months and less rapidly 
as life proceeds. Because cell changes are taking place 



THE GENERAL LAWS OF GROWTH 25 

so much more rapidly in the first decade than in the 
second, more rapidly in the second than in the third, 
etc., we may infer that the educational possibilities 
(considered also in percentile terms) decrease in similar 
proportion. The mental progress made by the child in 
the first year is in this sense infinitely greater than that 
of the tenth or the twentieth year. The possibilities of 
modifying the growth and physiological functioning of 
the various organs, including the central nervous sys- 
tem, rapidly diminish as the body cells assume their 
stable and mature characters. For the purposes of 
education youth is more important than manhood or 
womanhood, and childhood more precious than either. 
• (2) Oscillations in growth rate. In general, the curves 
for percentile increment in height and weight show 
a retardation of growth at or before school entrance, a 
slight acceleration at about 7 for girls and 8 for boys, 
a pre-pubertal minimum coming with girls at 9 and 
with boys at 11, followed by a rapid rise to the maxi- 
mum adolescent growth rate at the average age of 15 
for boys and 12i to 13 for girls. 

The exact significance for education or for hygiene 
of the oscillations in growth rate preceding puberty 
is unknown. As will later be shown there is reason 
to believe that the slight acceleration at 7 or 8 may 
be partly explained as a rebound from a preceding 
retardation caused by the child's entering school. It 
may be influenced also by the improvement in chewing 
surface which occurs at this time, due to second denti- 
tion. It is well established that the period of about 6 to 



26 THE HYGIENE OF THE SCHOOL CHILD 

7 is marked by an increased frequency of nervous and 
digestive disturbances. 

The revolutionary growth changes of adolescence 
must be interpreted in relation to the simultaneous 
transition, no less marked, in the instinctive, emo- 
tional, and intellectual life. It is not by accident that 
the curve for interest in mathematical puzzles (Lindley) 
and the curve for frequency of religious conversions 
(Starbuck) reach their maximum simultaneously with 
the curve of growth, and that they reveal almost ex- 
actly the same sex differences. The rapidity of growth 
at this time suggests the desirability of bringing to bear 
every possible influence that will aid in implanting and 
fostering desirable traits of mind and body before the 
mold has set. This principle is applicable alike to peda- 
gogy and to hygiene. The youth of 18 with crooked 
spine, undeveloped lungs, and diseased heart is hardly 
more hopeful from the point of view of hygiene than 
the juvenile delinquent from the standpoint of morals 
and religion. 

(3) Growth rate and resistance to disease. Investiga- 
tions on this point are somewhat contradictory, but 
indicate on the whole that, although the mortality rate 
is lowest when the adolescent acceleration is greatest, 
morbid conditions of both mind and body are at that 
time most frequent. This is particularly true of girls. 
It is necessary, however, to discriminate diseases and 
to determine the curve of liability to each. To lump 
together diseases and complaints of every kind and 
to enumerate them as so many "illnesses" or "de- 



THE GENERAL LAWS OF GROWTH 27 

fects'* is of doubtful value, at best, and may be mis- 
leading. 

(4) A comparison of the curves for girls and boys 
shows an important difference between the sexes. The 
girls reach their pre-pubertal minimum of growth rate 
a year or two earlier than boys and their maximum 
adolescent rate about three years earlier. Rotch and 
Boas have shown that the sex difference in physiologi- 
cal maturity amounts to more than a year by the age of 
5 years. The significance of "physiological age" dif- 
ferences is treated in chapter vi. 

(5) The relationship between physical and mental 
growth is a mooted question. In a sense, of course, men- 
tal growth must be supposed to rest upon some kind of 
physical basis, and the question resolves itself into that 
of the parallelism between growth in height or weight 
and development of the neural structure. There is no 
reason for believing the parallelism to be perfect, and it 
is a matter of common observation that a few children 
are mentally advanced beyond their own individual 
norm of height and weight while others are correspond- 
ingly retarded. This is but another way of saying that 
height and weight are not reliable indices of a child's 
physiological maturity. 

For masses, however, the relationship undoubtedly 
holds. Porter's data from 34,500 St. Louis children 
show distinctly that pupils of every age who are above 
grade are taller and heavier than pupils of the same 
age who are below grade. As an illustration of Porter's 
findings, the average weight of 11-year-old boys in the 



28 THE HYGIENE OF THE SCHOOL CHILD 

sixth grade was 73.34 pounds; in the fifth grade, 71.29; 
in the fourth grade, 69.24; in the third, 68.12; in the 
second, 65.45; and in the first grade, 63.5. The only 
studies of importance which fail to confirm this con- 
clusion are those of Gilbert and West, but their method 
of estimating intelligence (by using the teacher's clas- 
sification of "good," "average," or "dull") is unsuit- 
able for this purpose and in all probability accounts 
for their results. Since the large, dull, retarded pupils 
and the small, bright, advanced ones are found in the 
same class, the teacher is likely to overestimate the 
dullness of the former and the intelligence of the 
latter. 

Roberts's tables show that the professional classes 
of England are distinctly taller than any other social 
class, and that the professional men who are also Fel- 
lows of the Royal Society are above the average for 
professional men in general. Numerous investigations 
have demonstrated the average inferiority in height 
and weight of the feeble-minded. Goddard's figures 
indicate that the average idiot begins to fall below the 
average normal child at about 7 years, the imbecile at 
about 11, and the moron at 14. Shut tie worth found 
300 idiots and imbeciles to average 2 inches below 
normal at 10 years and 3 inches below at 15 years. 
Bayerthal's measurements of 1006 normal children of 
Germany show an unmistakable correlation, for masses, 
between head circumference and intelligence. All who 
have conducted measurements of mentally defective 
children agree in assigning them a smaller average 



THE GENERAL LAWS OF GROWTH 29 

circumference of head than is found among normal 
children of the same age. 

The conclusion, justified by the data, that physical 
superiority usually accompanies mental superiority, is 
of the greatest practical importance for education. 
The opposite opinion has been very widespread and 
has been made the excuse for the common practice of 
restraining the school progress of mentally superior 
children. In the exceptional case of intellectual pre- 
cocity accompanied by physical weakness, this is the 
wise course; but applied to supernormals as a class, the 
principle is unfavorable to the culture of genius and 
inimical to social progress. Instead of restraii^ng the 
talented child, we should encourage him to live up to 
his best possibilities. 

(6) The relation of 'pubertal retardation to ultimate 
size. Another law of growth somewhat related to the 
above, and of the greatest importance for hygiene, is 
that in case of delayed puberty adolescent acceleration 
is brief in extent and leaves the individual below the 
ultimate size of those who reach puberty early. In 
such children the growth energy of adolescence, though 
rapid, is too quickly expended to permit the gain of all 
that has been lost. This relation, which is quite the 
reverse of common opinion, holds for races as com- 
pared with one another and for different individuals in 
the same race. Hygiene, therefore, should look with 
suspicion upon all influences which artificially retard 
growth in the adolescent or pre-adolescent years. ^ 
1 See pages 100 and 210. 



30 THE HYGIENE OF THE SCHOOL CHILD 

REFERENCES 

1. Bayerthal: "Ueber d. Gegenwartigen Stand meiner Unter- 

suchungen ii. d, Beziehungen zwischen Kopfgrosse u. Intelligenz 

im schulpflichtigen Alter." Inter. Mag. School Hygiene, 1911, 

pp. 244-61. 

*2. F. W. Boas: "Growth of Toronto Children." Rept. of U.S. 

Commissioner of Education, 1896-97, p. 1541. 
3. H. P. Bowditch: "The Growth of Children." Eighth 4nnual 
Rept. of Mass. State Board of Health, 1875. (See also Tenth and 
Twenty-second Reports.) 
*4. F. D. Burk: "Growth of Children in Height and Weight." 

Am. Jour. Psych., ix, pp. 253-90. (Contains bibliography.) 
5. E. Chaumet: Recherches sur la croissance des enfants des icoles 
i de Paris. 1906, pp. 60. 

'? 6. W. S. Christopher: Measurements of Chicago School Children. 
Chicago, 1900. 
*7. H. Donaldson: The Growth of the Brain. 1900, chap. ii. 
*8. G. S. Hall: Adolescence. New York, 1904, vol. i, chap. i. 
9. W. S. Hall: "Changes in Proportions of Human Body." Jour. 
Anthr. Inst., Great Britain and Ireland, 1895, vol. xxv, pp. 
21-46. 

10. W. W. Hastings: Manual for Physical Measurements. Spring- 
field, Mass., 1902. 

11. Paul Hertz: Investigation of the Growth of Children in the Copen- 
hagen Elementary Schools. Reviewed in School Hygiene, 
August, 1912, pp. 175-78. 

12. E. Hitchcock: "Comparative Study of Measurements of Male 
and Female Students at Amherst, Mount Holyoke, and Wel- 
lesley." Proc. Am. Assoc, for Adv. of Phys. Ed., 1891, vol. 37. 

13. E. Hitchcock and H. H. Seeley: Physical Measurements of 
Young Men. Boston, 1893. 

*14. Lucy Hoesch-Ernst: Anthropologisch-psychologische Untersuch- 
ungen an Zuricher Schulkindern. 1906, pp. 143. 

15. Irving King: "Growth of Two Children." Jour. Ed. Psych., 
May, 1910. 

16. Koch: "Ein Beitrag zur Wachsthumsphysiologie des Men- 
schen." Zt. f. Schulges., 1905, pp. 293-319, 400-16, 457-92. 

*17. A. Macdonald: "Experimental Study of Children." Rept. 

U.S. Com. Ed., pp. 97-98, chapters xxi-xxv. (Contains 

bibliography.) 
18. H. Malling-Hansen: Perioden im Gewicht der Kinder und in der 

Sonnenwdrme. Copenhagen, 1881. 
*19. E. Meumann: Experimentelle Pddagogik. 1912, vol. i, pp. 63- 

131. 
20. Minot: Age, Growth, and Death. (See contents.) 
*21. G. W. Peckham: "Growth of Children." Sixth Annual Rept, 

State Board Health of Wisconsin, 1881, pp. 46. 
*22. W. F. Porter: "Growth of St. Louis Children." Trans. Acad. 

Sci. of St. Louis, vol. vi, p. 263. 



THE GENERAL LAWS OF GROWTH 31 

23. C. F. Roberts: Manual of Anthropometry. London, 1878. 

24. Samosch: "Ergebnisse von Schulkindermessungen u. Wagun- 
gen." Zt.f. Schulges., 1904, pp. 389 J". 

25. Schmidt u. Lessenich: "Ueber d. Beziehungen zwischen korper- 
licher Entwl. u. Schulerfolg." Zt.f. Schulges., 1903, pp. 1-7. 

26. F. W. Smedley: Report of Committee on Child-Study. Forty- 
sixth Annual Rept. of Board of Education. Chicago, 1899-1900. 
(Child Study Report, No. 2.) 

♦27. J. M. Tyler: Growth and Education. 1907. (See contents.) 

28. G. M. West: "Anthropologische Untersuchungen an Schul- 
kindern in Worcester, Mass." Arch, fiir Anthrop.^ 1893. 

29. H. Vierordt: Daten und Tabellen. Jena, 1893. 



CHAPTER IV 

THE FACTORS INFLUENCING GROWTH 

The factors which influence growth may be classed 
into two groups: (a) Internal or hereditary ^ including 
racial heredity, the influence of immediate ancestry, 
and the fact of sex. (h) External or accidental influ- 
encesy including malnutrition, acute and chronic dis- 
eases, bad housing, city life, overwork, lack of exercise, 
temperature, season of the year, air, ante-natal influ- 
ences, etc. 

(a) The internal factors 

Racial heredity. Racial heredity is of prime import- 
ance in determining both the ultimate size of the 
individual and the time of adolescence. Growth norms 
for the races of northern Europe, for example, cannot 
be used as standards for judging the growth status of 
Japanese, South Italian, or Spanish children. Stand- 
ards which represent averages of the measurements 
obtained from mixed groups of Scandinavian, English, 
Irish, German, French, Italian, and Russian children 
can have no meaning or legitimate use. 

It was formerly believed that nearly all primitive 
races, particularly those living in hot climates, are pre- 
cocious in their physical development. More recent 
investigations, however, tend to discredit this belief. 



THE FACTORS INFLUENCING GROWTH 33 

Reche's study showed that Melanasian girls reach pu= 
berty at an average of 16 to 17 years ; that Melanasian 
children are inferior to European children in size at all 
ages; that their final size is attained earlier; and that 
girls excel boys at all ages preceding adolescence. 
Baelz found the same principle of retarded puberty and 
early arrest of growth to hold also for the Japanese, 
though to a less degree, while children of mixed Japa- 
nese and European descent fell halfway between those 
of the pure stocks.^ Bobbitt (2) found from measure- 
ments of 1618 Philippine children, ages 6 to 21, that 
the pubescent acceleration almost coincides in time 
with that for American children, but that growth is 
arrested somewhat earlier. Compared to the mascu- 
line standard for her race, the Philippine girl is much 
superior in power of grip to the American girl. From 
the viewpoint of hygiene it would be interesting to 
know whether the inferiority of the American girls is 
inherent, or the result of pampering, indoor life, un- 
suitable dress, etc. 

Family heredity. The influence of immediate an- 
cestry is also an important determinant of growth. 
Children of the same parents show a high average 
resemblance in intelligence (brain growth), resistance 
to disease, and the like, as well as in height, weight, 
and various other bodily dimensions. Wiener's meas- 
urements of his four sons from infancy to maturity 
show that the fourth son, who was the offspring of a 

* For account of data from Reche and Baelz see Meumann's 
Experimentelle Padogogik, 2d edition, vol. i, p. 97. 



34 THE HYGIENE OF THE SCHOOL CHILD 

different mother, had a growth curve quite different 
from the other three. 

According to Karl Pearson and his co-workers in the 
Galton Eugenics Laboratory, the physical and mental 
resemblances of offspring to parent are marked by 
coefficients of correlation falling for most traits be- 
tween .40 and .50. This means that for any given trait 
the son may be expected to differ from the average from 
40 per cent to 50 per cent as much as the father does. 

The influence of age of parents on the growth 
curves of children is not known, but statistics of feeble- 
mindedness indicate that heredity is most favorable 
when the mother is between the ages of 20 and 40, and 
the father between 25 and 50. 

The relation of hygiene to eugenics. It is of the 
greatest urgency for hygiene that the heredity fac- 
tors, both racial and family, be separated from the 
influences of environment. It is folly for hygiene to 
aim at results which are attainable only through the 
agency of eugenics. Hygiene, for example, could do 
nothing for the cretins^ of Aosta beyond improving 
their conditions a little by humanitarian treatment; 
but the defect was practically eradicated in a few 
years by segregation of the male and female cretins 
during reproductive age. It is possible also that hered- 
ity is a more important factor in the production of 
tuberculosis, cancer, arterial sclerosis, and many other 
diseases than it is usually believed to be. The same 
may hold also for intelligence and traits of character. 

* See p. 55. 



THE FACTORS INFLUENCING GROWTH 35 

Neither hygiene nor eugenics should despise the scope of 
the other; each should confine its efforts to that which 
it is best fitted to accomplish. It would be especially- 
unfortunate if hygiene should neglect the limitations 
which a defective physical endowment places upon its 
best efforts. On every hand we see hygiene engaged 
in the effort to patch up the faults of heredity, and 
largely in vain. It is certainly the duty of euthenics ^ 
to make the best of the raw material at command, but 
the euthenist should not be satisfied to work forever 
with faulty material. Speaking generally, it is safe to 
say that most of the great plagues, both physical and 
moral, which afflict mankind will never be eradicated 
except by the united efforts of hygiene and eugenics.^ 

(b) The external factors 

The extent to which external factors may affect 
growth determines the value of corrective and hygienic 
measures. If unfavorable environment has only minor 
effect on normal growth tendencies, then the wisest 
precautions of hygiene will avail but little in correct- 
ing the deficiencies of growth. That external influ- 
ences are potent, however, is abundantly proved by 
data from many sources, though the exact extent to 
which they are operative is not always clear. 

Influence of economic and social conditions. The 

* Euthenics pertains to the favorable influences of environment. 
It is contrasted with eugenics, which refers to improvement of the 
race through application of the laws of heredity. 

^ Specific data bearing on heredity as a factor in causing various 
physical defects are reviewed in succeeding chapters. 



36 THE HYGIENE OF THE SCHOOL CHILD 

conditions which accompany bad social environ- 
ment are perhaps the most important, — unsuitable 
diet and clothing, crowding, inadequate ventilation, 
overwork, lack of parental care as regards sleep, exer- 
cise, personal habits, etc. No serious effort has ever 
been made to separate and measure the individual 
effects of these various factors, but the injury produced 
by the combined influence of all is revealed by the 
following representative findings.^ 

TABLE 3 

Social class I II III IV V VI VII VIII IX 

Number of cases 150 294 392 304 181 293 341 840 66 

Mean height (inches).... .... 55 54. 53.5 53. 52.5 52. 51.5 61. 60 

(Class I is highest, class IX lowest in social scale.) 

Superiority of children of non-laboring classes over 
children of laboring classes is shown in Table 4. 

TABLE 4 

Age 13 14 15 16 

Height superiority 

(inches) 2.66 3.35 2.89 3.47 

Weight superiority 

(pounds) 10.33 14.60 13.63 19.64 

Superiority in chest girth 

(inches) • 3.17 3.37 3.21 4.11 

Comparison of children of the best and worst classes 
in Edinburgh showed a difference of 5 pounds for boys 
and 10 to 12 pounds for girls in favor of the better 
classes. The difference in height was '^.65 inches for 
boys and 3.82 inches for girls (8, pp. 168 and 210). 
Grouping 72,857 children of Glasgow into four classes 
according to poverty gave a difference of 2.5 and 3.8 
inches for the ages 10 and 14 respectively, and a 

* Roberts's Manual of Anthropometry. London, 1878, p. 32. 



THE FACTORS INFLUENCING GROWTH 37 

difference of 3.2 and 5.1 pounds in weight for the same 
ages. Wilson found a difference of 9.2 pounds for boys 
and 6.8 pounds for girls between the slum children of 
Birmingham and the children of a model town in the 
near vicinity (13). Arkle found children of the best 
class superior to those of the poorest class by 3.8 
inches and 6.3 pounds at 7 years, and by 6.5 inches and 
23 pounds at 14 years (1); Comparing several thou- 
sand 14-year-old children of the artisan class with 
children of the most favored class, Dukes finds the 
former inferior by 3.35 inches in height and 14.59 
pounds in weight. 

In Freiburg, Germany, Geissler's and Uhl^sche's 
measurements of 1,874 children showed a superiority 
of boys of the better classes varying from 2.4 centi- 
meters at 6 J years to 4.7 centimeters at 13. The cor- 
responding figures for girls ranged from 3.9 centimeters 
at 6^ years to 5.1 at 13. 

Similar differences have been discovered by many 
other investigators in various parts of Europe and 
America. The contrast appears also in the populations 
which are the most homogenous, racially, and almost to 
the same extent as where the upper and lower classes 
differ in racial heredity. In some cases social class is 
even more potent in determining size than race itself.^ 

When conditions are unfavorable enough to affect 
growth in height and weight it is reasonable to suppose 
that the effects would extend to many of the organs of 
the body and to their physiological functioning. That 

^ Hoesch-Ernst. 



38 THE HYGIENE OF THE SCHOOL CHILD 

such is the case seems to be well established. One of 
the main effects is the delay of puberty and the abbre- 
viation of the period of accelerated adolescent growth. 
The children of the poor, on the average, reach puberty 
late and cease growing early. Meyer's figures for 6000 
German girls showed a difference of four fifths of a 
year in the average age of puberty between the wealthy 
and the poor classes. The extensive investigations of 
Key, Roberts, and the English Anthropometrical Com- 
mittee agree that the onset of adolescence is delayed 
from one to two years with the lower classes. In such 
cases the adolescent growth comes with a rush, is 
abnormally rapid for a relatively brief period, and 
comes to a standstill before the earlier losses have been 
made good. In every respect this unnatural course of 
growth is less favorable than a steady growth through a 
longer period. Disturbances of physiological functions, 
disharmonies of growth, physical defects, anaemia, 
nervous instability, etc., are more likely to occur. 
Statistics of medical inspection confirm this by show- 
ing a larger amount of defectiveness of almost every 
kind among the children of the poor. 

Analysis of environmental influences. What is the 
relative amount of influence exerted by the numer- 
ous factors which accompany poverty? Science has 
solved harder problems, but has not yet set itself 
seriously about the solution of this one. Our univer- 
sities have accomplished more toward ascertaining 
the optimum growth conditions for corn, wheat, and 
hogs than for children. Thus far we have little sci- 



THE FACTORS INFLUENCING GROWTH 39 

entific basis for assertions regarding the individual 
effect upon healthy growth of insufficient sleep, under- 
feeding, inadequate clothing and shelter, lack of oppor- 
tunity for play, overwork, child labor, neglect of per- 
sonal hygiene, etc. 

By classifying Edinburgh children according as they 
lived in houses of one room, two, three, four, or more, 
Mackenzie was able to show a progressive increase in 
height and weight with better housing conditions; but 
this gives us little clue to the effect of housing itself, 
since children who live in one-room houses are also 
at a disadvantage as regards sleep, play, work, food, 
parental care, etc. Measurements showing j^e sub- 
normal size of factory children in the Southern States 
are just as little enlightening as to the influence of 
child labor on growth. The marked differences found 
by Hertz, Hoesch-Ernst, and many others between city 
and country children are more decisive as to the whole- 
some influence of rural life. Country children are dis- 
tinctly superior to city children of the same social class 
in height, weight, chest girth, and power of grip. The 
chest girth of country girls approaches much nearer to 
the average for boys than is true of girls in the cities. 

Nutrition, Of all the factors concerned, however, 
we have reason to believe that the nature and the 
quantity of food are the most important. Adequate 
nutrition is the necessary foundation of healthy growth, 
and the lack of it the most productive cause of the 
low vitality which favors tuberculosis and certain other 
diseases. There is hardly a defect found among school 



40 THE HYGIENE OF THE SCHOOL CHILD 

children which is not in greater or less degree produced 
by malnutrition. In this category we may include even 
eye-strain, dental defects, spinal curvature, and nerv- 
ousness, as well as the infectious diseases. Children 
in open-air schools where feeding is practiced gain 
promptly and continuously in weight, and hold the 
advantage gained.^ It is impossible, however, without 
further researches, to apportion the credit for this 
among the numerous factors involved, — fresh air, 
exercise, decreased study, feeding, sleep, medical and 
nurse attendance, etc. That the entire regimen of the 
open-air school exerts a powerful influence on crude 
growth is perfectly well established, and the influence 
on the physiological functions appears to be even more 
pronounced. 

One further point deserves emphasis. The investi- 
gations indicate that the influence of poor nutrition in 
the early years tends to last throughout the growth 
period. Whether the child will reach a normal adoles- 
cence and maturity is partly determined before he 
starts to school. As is shown in chapter viii, the resist- 
ance of the permanent teeth to decay is partly deter- 
mined in the first years of childhood. Russow's growth 
measurements of the same children for eight years show 
that artificially nourished children fall behind the 
breast-fed from two to three kilograms in the first year 
and do not catch up. It is possible, however, that 
mothers who are unable to nurse their children are 

* See chapter xii of Health Work in the Schools, Hoag and 
Terman. 



THE FACTORS INFLUENCING GROWTH 41 

subnormal in physical endowment and that the chil- 
dren merely inherit a low-grade constitution. Thus, at 
every turn, we are confronted with the baffling com- 
plexity of the problems of growth. 

The main argument for breast feeding is the insur- 
ance it offers against infant mortality. The artificially 
fed child, if it survives the first year, is usually normal 
in gross size, though likely to be defective in physio- 
logical development, as is shown by the statistics for 
rickets, dental defects, spinal curvatures, etc. 

On the whole, we may say that that deprivation, 
malnutrition, etc., must be long continued in order to 
produce any permanent stunting effects. Minol proved 
that young guinea pigs temporarily starved until they 
were only two thirds of the normal weight for their age 
were able to make good almost the entire loss with 
return to normal diet. The same is true of temporary 
illnesses, which, as a rule, produce a prompt disturb- 
ance of growth later compensated by a corresponding 
acceleration. The fact that poverty does produce a 
marked and permanent stunting effect has, therefore, 
the greatest significance. 

The evils of malnutrition are perhaps best illustrated 
by the effects of the hookworm disease upon the growth 
of children. As is well known, the disease is caused 
by the hookworm parasite, a small worm about a half- 
inch in length, which finds its way into the alimentary 
tract. There it attaches itself in great numbers to 
the walls of the intestines and feeds. By frequently 
attaching and detaching themselves the parasites 



42 THE HYGIENE OF THE SCHOOL CHILD 

cause hemorrhages, ulcers, thickenings and degenera- 
tions of the intestinal linings, hindering in this way 
the normal processes of digestion as well as causing a 
certain loss of blood. Children who have suffered for 
some time from the disease are pale, undersized, ema- 
ciated, mentally dull, and of low vitality. The number 
of red corpuscles may fall to 60 per cent of the normal 
and the haemoglobin still lower. The liver and spleen 
are enlarged, and most of the other organs are affected 
in one way or another. The physiological development 
may be retarded several years, as is interestingly shown 
in the radiographs facing page 63. The condition in 
the main is one of extreme malnutrition, though it is 
possible that the effects are in some measure due to 
toxins produced by the parasite and injected into the 
blood. In every respect growth and development are 
interfered with, and to an extent proportional to the 
number of parasites. 

Glandular influences. Normal growth is known to 
be conditioned by the activity of certain glands, par- 
ticularly the thyroid. If the thyroid is congenitally 
absent or defective, cretinism results, a condition of 
mental defectiveness with misshapen dwarfishness of 
body. If treatment is begun early enough, thyroid 
deficiency may to a certain extent be made good 
by a diet including an artificial thyroid preparation 
made from the glands of sheep. It is possible in this 
way to rescue children to a normal life who otherwise 
would be doomed to helpless idiocy. "Within six 
weeks a poor, feeble-minded, toad-like caricature of 



THE FACTORS INFLUENCING GROWTH 43 

humanity may be restored to mental and bodily 
health." ^ 

To be of much avail, however, the diet must be con- 
tinued from early infancy until growth is completed. 
Thyroid diet does not materially improve the condition 
of feeble-minded children other than cretins. More 
rarely, certain organic defects are produced by over- 
activity of the thyroid gland. ^ 

Growth rhythms. Marked seasonal influences on 
growth were established by the painstaking investi- 
gation of Malling-Hansen (9), who measured the 
height of seventy boys daily for two years and the 
weight for three years. For height, the season of 
maximal growth extends from the end of March to 
the middle of August; the minimal period from 
August until the middle of November. For weight, 
the figures are almost exactly reversed, maximal 
growth extending from August to September and 
minimal growth from the end of April to the end of 
July. This investigation was made in Copenhagen. 
Data are not available to inform us how the growth 
rhythm in the South Temperate and Torrid zones dif- 
fers from that of the North Temperate. Why children 
advance in height most rapidly in the spring and early 
summer and gain most weight in the late summer and 
early fall is not known, but the fact is an important 
one to be kept in mind by those who interpret growth 

* Osier, Practice of Medicine, 1909, p. 771. 
^ Graves's Disease, sometimes treated by surgical removal of part 
of the thyroid gland. 



44 THE HYGIENE OF THE SCHOOL CHILD 

records. Otherwise, regiraen may get the credit or the 
blame for growth changes due to the earth's revolution 
around the sun! 

It is interesting to note that the law which states that 
"rapid growth in height immediately precedes rapid 
growth in weight" holds for each individual year as 
well as for the pubertal acceleration. It is also signifi- 
cant that the rapid growth in height is in part coinci- 
dent with a period of high fatiguability and mental 
sluggishness, while the fall period of rapid growth in 
weight marks a rapid rise in the seasonal curve of the 
power to attend.^ Daily, weekly, and monthly rhythms 
have also been detected, but these are slight and of 
no special importance for school hygiene. 

School influence. Is the influence of school life suf- 
ficient to affect growth in height and weight? The data 
justify an affirmative answer, particularly as regards the 
period immediately following school entrance. ^ That 
the initiation of the child into the life of the school should 
prove such a profound shock as to affect the growth of 
the entire body forcibly suggests the desirability of 
reforms that will make the transition from home to 
school more easy and natural. There is no reason why 
the school should be less healthful than the average 
home. It ought to be more healthful than the average 
home, and until it is made so the campaign for school 
reform should continue. Open-air classes point the 
ideal by demonstrating that it is as possible for the 
school to create health as to destroy it. The fact that 
Copenhagen children of to-day considerably outrank 

^ See chapter xx. 2 ggg p 338. 



THE FACTORS INFLUENCING GROWTH 45 

those of thirty years ago both in stature and weight - 
is evidence that medical inspection, shorter programs, 
school feeding, and other educational reforms have 
there borne fruit. 

Pre-natal influences on post-natal growth and devel- 
opment are little known. From the evidence available 
it appears that overwork and underfeeding of the 
mother during pregnancy reduce the size of the off- 
spring at birth and materially increase the probability 
of death in the first few months, but that if the early 
dangers are safely weathered the child will grow nor- 
mally in height and weight. Paton was able to reduce 
the size of guinea pigs at birth 25 per cent by sj^rving 
the mother during pregnancy. Newman's important 
work on infant mortality shows clearly that overwork 
during pregnancy is a frequent cause of premature 
birth and consequent infant mortality. 

The use of alcohol by the expectant mother is com- 
monly believed to be productive of idiocy and of vari- 
ous kinds of disease and deformity in the offspring. The 
recent researches of the Galton Eugenics Laboratory, 
however, give no support to this belief. On the other 
hand, Stockard has plainly demonstrated that paren- 
tal alcoholism in guinea pigs influences both the num- 
ber and healthiness of the offspring. "Forty-two mat- 
ings of alcoholic guinea pigs have given only eighteen 
young born alive, and of these only seven, five of which 
are runts, survived for more than a few weeks; while 
nine matings of non-alcoholic guinea pigs have given 
seventeen young, all of which have survived and are 
} See School Hygiene, 1912, pp. 175 ff. 



46 THE HYGIENE OF THE SCHOOL CHILD 

normal, vigorous individuals. These facts convinc- 
ingly demonstrate the detrimental effects of alcohol on 
the parental germ (of guinea pigs) and on the develop- 
ing offspring" (11, p. 297). This is in agreement with 
Hodge's well-known experiments on the effects of 
alcohol upon dogs. 

The indirect injury which alcohol works upon chil- 
dren by depriving them of adequate food, clothing, 
shelter, and education is undisputed, and we are al- 
ways in danger of mistaking this indirect influence for 
a direct effect of alcohol upon the germ cell itself. 

REFERENCES 

1. A. S. Arkle: "The Physical Condition of Children attending 
Elementary Schools." Lancet, 1907, p. 127, 

2. J. F. Bobbitt: "The Growth of Philippine Children." Fed. 
Sem., 1909, pp. 137-68. 

*3. F. Boas: "The Growth of Children." Science, December 13, 

1912, pp. 815-18. 
*4. Frederic Burk: "The Influence of Physical Exercise upon 

Growth." Am. Phys. Ed. Rev., 1899, pp. 340/. 
*5. Ethel M. Elderton: "The Relative Strength of Nurture and 

Nature." Eugenics Laboratory Lecture Series, iii, 1909, p. 40. 
[ 6. Landsberger: "Das Wachsthum im Alter der Schulpflicht." 

Archivf. Anthropologic, vol. xvii, pp. 229-64. 

7. Arthur Macdonald: "Experimental Study of School Children." 
Rept. of U.S. Commissioner of Education, 1897-98, pp. 1119 Jf. 

8. W. Leslie Mackenzie: The Medical Inspection of School Chil- 
dren. 1904, pp. 139-48 and 204-14. 

9. P. Malling-Hansen: Perioden im Gewicht der Kinder. Kopen- 
hagen, 1886. (Reviewed by Burk.) 

10. T. Misawa: "A Few Statistical Facts from Japan." Ped. Sem., 
1909, pp. 104-12. 

11. Charles R. Stockard: "An Experimental Study of Racial 
Degeneration in Mammals treated with Alcohol." Archives of 
Internal Med., 1912, pp. 369-98. 

*12. N. W. Wiazemsky: Influences des diferents facteurs sur la crois- 
sance humaine. 1907, p. 400. 

13. Dr. H. B. Wilson: "The Physical Condition of Slum Children." 
Lancet, 1906, pp. 549 /. 

14. See also Burk, Hall, Hoesch-Ernst, and other references given 
at the end of chapter iii. 



CHAPTER V 



SOME PHYSIOLOGICAL DIFFERENCES BETWEEN 
CHILDREN AND ADULTS 

General differences 

Every organ has its own growth rate and its own 
critical periods of 
development. 
Measurements of 
height and weight 
give us little notion 
of the complexity 
of the processes 
taking place with- 
in. Judged by size 
alone, the child 
might be looked 
upon as like the 
adult, only small- 
er. Nothing could 
be farther from the 
truth./ The child 
is different from 
the adult in every 
fiber, every blood 
corpuscle, every 
bone cell, and in 
the relative pro- 




FIG. 3 

This plate is specially designed to show how much 
the proportions of the new-born child ditfer from 
those of the adult. To make this difference more 
striking, the skeleton of a new-born child (A) and 
that of an adult (C) are here represented drawn 
on different scales. (B) represents the new-born 
child drawn on the same scale as (C). (From a 
photograph by Prof. Sanford published by S. Hall, 
Adolescence, I.) — D. Appletou & Co. 



48 THE HYGIENE OF THE SCHOOL CHILD 

portions of all his parts. His resistance to disease, his 
powers of recuperation, his food and sleep require- 
ments are all unlike those of the adult. He is differ- 
ently affected by every element of environment and 
regimen. Child hygiene and child physiology are far 
from synonymous with the hygiene and physiology of 
the adult. 

The newborn child is largely trunk and head. Most 
of his vital organs are much nearer the adult size than 
are his height and weight. The trunk is long, the head 
is as broad from side to side as the shoulders, and the 
legs are diminutive. Plainly the little child is a sessile 
organism whose main business, judging from the dis- 
proportionate size and activity of the vital organs, is 
to keep alive and to grow. As revealed in the figure 
on page 47, the relative size of his parts is such that 
an adult retaining the exact infantile proportions 
would strike us as a misshapen monster. 

Differences in the Circulatory System 

The child's blood contains fewer red corpuscles than 
that of the adult, and their "disintegration quotient" ^ 
is somewhat different. Children are more prone to 
anaemia than adults. The white corpuscles are in all 
somewhat more numerous, but of these relatively few 
have germicidal power. For this and other reasons the 
child's resistance to certain diseases is significantly 
inferior. As shown by Mouton, if the child contracts 

1 This term refers to the readiness with which the corpuscles 
yield up their oxygen to the tissues. 



CHILDREN AND ADULTS 49 

measles in the first year of life the chances are about 
one in five that he will not recover. From one to three 
or four years the chances of death are one to twenty- 
five, and if measles can be postponed until after the 
sixth year the probability of death is reduced to about 
one in two hundred and fifty. Whooping-cough is an- 
other disease which is more dangerous for the infant 
than typhoid fever or smallpox for the adult. 

The child's heart, compared to his arteries, is small, 
and must beat with great rapidity to maintain the nor- 
mal pressure of blood. During growth the width of the 
aorta increases only three times; that of the heart 
twelve times. The adult ratio between heart aliid arte- 
ries is not attained until the later years of adolescence, 
previous to which time all exercises and games making 
heavy demands on strength or endurance are danger- 
ous. In shape, also, and in its position in the thoracic 
cavity, the child's heart is significantly different from 
the adult's. 

The lymphatic system of the child plays a much 
greater role in nutrition and in resistance to disease 
than is true of the adult, and since the flow of lymph 
is so largely dependent upon muscular activity, seden- 
tary habits are particularly injurious to health in the 
years of childhood. Associated with this greater activ- 
ity of the lymphatic system in the early years there 
is a marked tendency to hypertrophy of the lymphatic 
tissues (adenoids, enlarged tonsils, etc.) and a special 
liability to disease of the lymph glands. 



50 THE HYGIENE OF THE SCHOOL CHILD 

The digestive system 

The digestive system of the child is different through- 
out its course from that of the adult. Dentition is 
not complete till adult life. The mouth glands which 
secrete ptyalin, the starch-changing ferment, are en- 
tirely inactive for months after birth and only gradu- 
ally assume their proper functions. The child's stomach 
is tubular and more vertical than in the adult and has 
weaker peristaltic movements. The gastric secretions 
are functionally quite different from those of the adult 
in that they lack the power of dissolving the cell walls 
in the food and freeing the proteids. The intestines, 
likewise, are different in position, secretions, functions, 
and relative size. The liver at birth is one eighteenth 
the size of the body, while with the adult, it is one 
thirty-sixth the size of the body. 

Metabolism is far more rapid in children than in 
adults. A child of three years requires 40 per cent as 
much food as the adult, though the size of the body is 
less than 20 per cent as great. Because the surfaces of 
similar solids compare as the squares and their bulk as 
the cubes of their linear dimensions, it comes about that 
the child of 6 has about 60 per cent more body surface 
in proportion to weight than has the adult. This in- 
volves far more rapid heat loss and necessitates rela- 
tively greater heat production. The infant consumes 
from four to five times as much oxygen as the adult per 
unit of weight, and the child of 6 years about twice as 
much. The amount of carbon dioxide exhaled is cor- 
respondingly greater. 



CHILDREN AND ADULTS 51 

It is not strange, therefore, that any disturbance of 
the factors which influence metabolism, such as insuflS- 
cient food, deprivation from exercise, lack of fresh air, 
etc., produce their ill effects upon the child more quickly 
than upon the adult. The child's reserve of energy is 
small; his fatiguability is high; he is quickly brought 
to exhaustion. This is as true for the brain as for the 
muscles. For the younger school child, short periods of 
work should alternate with short periods of rest. Two- 
and three-hour school sessions without rest are always 
unhygienic for young children, possibly also for older 
ones. We have only to watch the rapid and spontane- 
ous alternations of activities in children's unsupervised 
play to find the law which should serve as the funda- 
mental guide in the making of all school programs. 

The respiratory system 

Lung capacity follows closely the curve of weight, 
and is therefore a valuable index of vitality. The ratio 
between lung capacity and weight is called the "vital 
index." De Busk (3) finds the vital index smaller for 
children below grade than for children not retarded. 
Although from 11 to 14 years, girls exceed boys in 
height and weight, they fall below boys in lung capac- 
ity at every age. This is probably due, in part, to the 
sedentary and indoor life led by girls, and is very im- 
portant when considered in relation to the excessive 
mortality of adolescent girls from tuberculosis and 
their tendency to anaemia. Girls of primitive races, 
and American and European girls who live in the coun- 



52 THE HYGIENE OF THE SCHOOL CHILD 



try, approach more nearly to the average vital capacity 
of their brothers. The fact that girls breathe more with 
the upper part of the chest than do boys is traceable 
in some degree to dress and sedentary habits, in part 
to structural causes. Exercise and habits of breathing 
both have an astonishing influence on vital capacity, 
which has been known to increase as much as three 
hundred cubic centimeters in three months. Deep 
breathing helps to determine the rate of oxidation of 
the blood, but is less a factor in this than exercise. 

The size of the lungs, however, is probably less re- 
lated to health than is their right use. The chief danger 

lies in harboring 
unused lung tissue. 
The importance of 
right lung devel- 
opment and the 
cultivation during 
childhood and ado- 
lescence of right 
habits of breathing 
and exercise can 
hardly be over- 
estimated. The fate 
of those who have a 
tendency to tuber- 
culosis is usually 



c.c. 

3600 
3400 
3200 
3000 
2800 
2600 
2400 
2200 
2000 
'l800 
1600 
1400 
1200 
1000 



























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7 8 9 10 11 12 13 14 15 16 17 18 



FIG. 4 

Showing increase in lung capacity. (From Smed- 
ley's table.) 



sealed before the close of the adolescent period. Smed- 
ley found a direct correlation between vital capacity 
and school progress.^ 
* For relation of vital capacity to nasal obstructions see chapter xii. 



CHILDREN AND ADULTS 53 

The accompanying curve, based on Smedley's Chi- 
cago study, gives the norms of vital capacity for the 
ages 6 to 18. 

The muscular system 

On the laws of muscular development, if the related 
facts were fully at our command, an entire philosophy 
of education could be based. The child's muscles, 
individually and collectively, differ from those of the 
adult in accuracy, strength per unit of cross-section, 
bilateral symmetry, ability to take on training, deli- 
cacy of coordinations, etc. The muscular system of 
the newborn child is 23.4 per cent of the weight 
of the entire body, that of the adult, 43 pe* cent. 
Moreover, the child's muscles contain relatively a 
much greater proportion of water, and are even more 
inferior in function than in size or weight. 

The order of development for individual muscles and 
sets of muscles is of greater significance for hygiene than 
their growth considered en masse. The well-known law, 
that voluntary control (for both rate and accuracy) of 
the "fundamental " muscles develops before that of the 
"accessory," has immediate and obvious application in 
manual and industrial training, drawing, writing, play 
instruction, gymnastics, sports, and in the arrangement 
of the school program. Plays, manual exercises, or 
instruction of any kind demanding delicate coordina- 
tions of the accessory muscles (the fingers and hands, 
for example) should have no place in the kindergarten 
and need to be subordinated in the first two or three 
years of the grades. Excessive employment of the 



54 THE HYGIENE OF THE SCHOOL CHH^D 



accessory muscles, to the neglect of the fundamental, 
often gives rise to symptoms of nervousness such as 
those associated with morbid precocity. The modern 
school program, with its over-use of the muscles of the 
eye in reading and of the hand in writing, coupled with 
the still more injurious neglect of the large muscles 
of the arms, trunk, and legs, constitutes a universal 

menace to healthy 
growth. Children's 
bodies, in every 
bone, muscle, and 
vital organ, are 
likely to suffer in 
their development 
from the sedentary 
regimen of the 
school. 

Growth norms of 
muscular strength, 
as measured by power of grip, are shown in the ac- 
companying curves from Smedley. 

The reader should be reminded that the various mus- 
cles of the legs, back, shoulders, etc., have curves of 
growth in strength entirely peculiar to themselves, and 
that the curves for strength do not parallel even ap- 
proximately those for accuracy and speed. All of this 
is set forth clearly in the admirable summary to be 
found in Hall's Adolescence. 

In general, boys excel girls in strength (relative to 
weight) ; also in speed and accuracy as measured by the 



K.G. 

. 50 

48 

46 

44 

.42 
■• -40 

88 

36 

84 

32 

'80 

^' 28 

26 

•24 

22 

20 

18 

16 

14 

12 

10 

Age 6 7 8 9 10 11 12 13 M 15 16 17 18 

FIG. 5 

Showing increase in strength of grip for right hand. 
(From Smedley's table.) 

























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CHILDREN AND ADULTS 55 

usual tests. In strength of grip, American girls fall 
further below the average for boys than do the Philip- 
pine girls. 

Attempts to correlate motor functions with intelli- 
gence in normal children have given widely contra- 
dictory results, but the feeble-minded as a class are 
decidedly inferior to normal children in strength of 
grip, rate of tapping, accuracy in tracing complex fig- 
ures with a pencil, and in the coordinations requisite 
for the usual school work in manual training. Back- 
ward children are especially retarded and uncertain in 
developing control of the accessory muscles. 

Much has been written about the hygienic asp^ts of 
our system of unidextrous education, some hygienists 
believing that our comparative neglect of one half of 
the body involves certain dangers to health and even to 
brain growth. Unidexterity certainly tends to produce 
bilateral asymmetry, to favor one lung at the expense of 
the other, and to bring about lateral curvatures of the 
spine. Indirectly, through the posture, the eyes also 
may be influenced. But the advantages of specializa- 
tion are so great that proposals to cultivate perfect 
ambidexterity in all children cannot be taken seriously. 
The backward and feeble-minded are less often unidex- 
trous than normal children. This is due chiefly to 
relatively lower development of control of the right 
side, so that the feeble-minded may be said to have, in 
effect, two left hands. 



56 THE HYGIENE OF THE SCHOOL CHILD 

The skeletal system 

As regards the development of the skeletal system, 
the fact of greatest significance for hygiene is the ex- 
treme slowness with which ossification takes place and 
the consequent possibility of deformity from incorrect 
posture, lack of exercise, etc., during the growth period. 
Much that is rigid bone in the adult is soft cartilage in 
the child, and the whole skeletal system of the latter is 
plastic to a degree which is rarely appreciated.^ The 
ossification of the jaws is not complete till some time 
after puberty, so that severe deformities of the lower 
part of the face may be caused or cured up to this time. 
The shape of the entire head and the proportions of all 
its parts continue to undergo marked transformation 
till well toward the close of adolescence. Even the 
orbit of the eye assumes its final shape only gradually, so 
that the younger children are prone to hyperopia and 
older ones to myopia.^ 

In the child there is a suture in the roof of the middle 
ear which permits easy connection by blood vessels 
between the middle ear and the dura mater membrane 
covering the brain. This helps to explain the frequency 
with which mastoid complications arise in the case of 
middle-ear infections with children. Associated with 
this is the fact that the child's ear is relatively closer 
to the throat than the adult's, and that the eustachian 
tube, which forms the connection, is straighter and 
wider, both relatively and absolutely. It is because of 
this short, straight, and broad road from the throat to 
} See chapter vii. 2 g^g chapter xiv. 



CHILDREN AND ADULTS 57 

the middle ear that throat infections in children make 
the journey so readily.^ 

The nervous system 

Compared to the rest of the body, the central nerv- 
ous system shows a precocious growth in size and 
weight. At birth the brain has already attained about 
one fourth of its final size, and by 7 years over 90 per 
cent. Growth continues much retarded up to about 14, 
and then practically ceases. But here, least of all, does 
weight give any idea as to maturity. The cells of the 
brain, though all present in embryonic, granule form 
for several months preceding birth, only gradi^lly 
ripen into their fully differentiated structure and put 
forth their branching network of dendrites. So unripe 
is the brain at birth that the neural functioning of the 
newborn child may be compared with that of Golz's 
dogs whose brains had been removed. Only the raw, 
instinctive reflexes are present. 

The acquisition of the medullary sheath, which we 
have above spoken of as the ripening process, proceeds 
rapidly in the sensory and motor centers and more 
gradually in the frontal portion, named by Flechsig the 
"association centers." This includes almost two thirds 
of the cerebral cortex, which, together with the middle 
sheath of tangential fibers, shows remarkable and 
important changes in the cellular development of later 

* The most common diseases of the bones during childhood, 
rickets and tuberculosis, are discussed elsewhere. See pages 79 
and 129. 



58 THE HYGIENE OF THE SCHOOL CHILD 

adolescence, the changes continuing probably as late 
as 40 years. That this is coincident with an equally 
marked intellectual growth suggests the futility of the 
premature culture of rationality and the highest ethi- 
cal traits of character. The lack of judgment, the irre- 
sponsibility, and the mental unripeness of youth have 
a more material basis than the mere lack of experience. 
Developed brain cells are necessary and a rich network 
of connections. 

Again we see how growth is capable of solving some 
of the most difficult pedagogical problems. We cannot 
teach little children to sit still, and should not if we 
could; but if we will only wait till those higher centers 
have developed which make voluntary inhibition pos- 
sible, we shall find our pedagogical problem has van- 
ished. The youth can sit still without being taught. 
Only a little patience is necessary to dispose of many 
another pedagogical dilemma in the same way. 

But time alone does not suffice. Brain centers which 
are little used do not develop normally. The visual 
and auditory centers of Laura Bridgman's brain were 
found, after her death, to be in the infantile, unripe 
condition; small, granular, primitive cells with few 
branches. The development of the brain is fostered 
best by a play life which is rich and varied and by 
educational exercises suited to its stage of immaturity, y 
The use of the brain in varied physical and mental 
activities improves its circulation, its nutritional proc- 
esses, and therefore its finer development and highest 
functioning. Probably also it delays the degenera- 



CHILDREN AND ADULTS 59 

tive processes of old age, for senescence, unfortunately, 
does not leave the brain unaffected. 

After 50 or 60, the weight materially decreases, the 
neuroglia — the supporting, non-nervous connective 
tissue — encroaches more and more upon the domains 
of the nervous tissue proper, and the cells of the latter 
become heavily pigmented and shrunken like the gan- 
glion cells of a frog which have been electrically stim- 
ulated to the point of exhaustion.^ Many of the cells 
even disintegrate and are carried off as waste prod- 
ucts. The processes of decay seem to occur late in 
the life of the mental worker and prematurely in those 
whose labor is mostly physical. This, coupled ^ith 
the fact that cerebral development continues well on 
into middle life, is an added argument for the estab- 
lishment of educational institutions for adults; likewise 
for such alterations of social and industrial institu- 
tions as will enrich in any degree the intellectual life 
of those whose work is not predominantly mental. 

Lack of harmony and regularity in growth 

Growth throughout the body, whether we compare 
the organs of different systems or different parts of 
the same system of tissues, progresses with the greatest 
irregularity. Wherever we look we fail to find any such 
thing as an even, regular, harmonious growth. The 
heart follows a curve different from that of the arteries, 
the muscles of the leg different from those of the fore- 
arm, the bone of the upper leg different from those of 
^ See reference 4, chapter xvii. 



60 THE HYGIENE OF THE SCHOOL CHILD 

the lower, etc. As stated by Hall, every organ has its 
own growth inning. A good illustration is the compari- 
son between the growth of trunk and legs. In the first 
triennium the trunk's percentage increment for length 
is two thirds that of the legs ; in the second triennium, 
one half; in the third triennium, one fourth; and in 
the fourth triennium, again one half. The excessive 
growth of the legs from nine to twelve years is not only 
destructive of bodily grace, but may act as a drain and 
tax upon the activity of the heart and other organs. 

Most impressive also is the lack of permanency in 
the form, structures, and functions of the child's or- 
gans. From first to last, developmental changes are 
more important than those of mere growth. It is un- 
safe, a priori^ to infer that anything which is safe or 
beneficial for the adult is hygienic for the child. Child 
hygiene, we may repeat, in both its mental and its 
physical aspects, must be cultivated as a distinct and 

separate field. 

REFERENCES 

1. W. L. Bryan: "The Development of Voluntary Motor Abil- 
ity." Am. Jour. Psych., 1892. 

2. Frederic Burk: "From Fundamental to Accessory in the Devel- 
opment of the Nervous System and of Movements." Ped. 
Sem., 1898, pp. 60. 

3. B. W. De Busk: "Height, Weight, Vital Capacity, and Retard- 
ation." Ped. Sem., 1913, pp. 89-92. 

4. H. Donaldson: The Growth of the Brain. 1900, pp. 374. 
*5. G. Stanley Hall: Adolescence, vol. i, chaps, ii and iii. 

*6. Nathan Oppenheim: The Development of the Child. 1898, pp. 
11-65. 
7. M. Probst: "Gehirn u. Seele des Kindes." Samrrd. u. Abh. aus 

dem Gebiete der Pad Psych, u. Physiol., Berlin, 1904. 
*8. J. M. Tyler: Growth and Education. (See contents.) 
9. Vierordt: Physiologic des Kindesalters. 
10. See references to chapters iii and vi; also standard texts on 
physiologies. 



CHAPTER VI 

THE EDUCATIONAL SIGNIFICANCE OF 
"PHYSIOLOGICAL AGE" 

Distinction between chronologicaly anatomical and 
physiological ages 

The reader is already familiar with the fact that not 
all children of a given age are equally advanced in a 
physiological sense. The number of years a child has 
lived we may designate as his "chronological ag^" In 
contradistinction to this, the stage of maturity which 
the child has attained may be designated his "physio- 
logical age." The term "anatomical age" is some- 
times used in reference to the successive stages in the 
anatomical development of the individual. 

It is well to keep clearly in mind this distinction be- 
tween chronological age, on the one hand, and physio- 
logical or anatomical age, on the other. These run by 
no means a parallel course. A boy who has lived six- 
teen years may be no more mature, physiologically, 
than another who has lived only twelve. Differences 
in physiological age amounting to two or three years 
are extremely common in children of the same chron- 
ological age. Given a miscellaneous group of boys 
whose chronological ages all fall within one month of 
fourteen years, there are likely to be some in the group 
who are two years past the age of puberty and others 



62 THE HYGIENE OF THE SCHOOL CHILD , 

who will not become pubescent for two or three years* 
For medical, pedagogical, industrial, and social reasons ^ 
it is sometimes more important to know the physio- 
logical age than the chronological. 

For opening up the field in a definite way we are 
indebted chiefly to two important and painstaking 
investigations: (1) that of Hotch and Pry or on the 
anatomical stages in skeletal development, and (2) 
Crampton's study of physiological development as 
marked by pubescence and dentition. 

Anatomical age 

In studying the process of ossification by means of 
the Roentgen rays, Rotch and Pryor found well- 
defined stages in the transformation of cartilaginous 
tissue into osseous. These stages always succeeded each 
other in the same order. The stages appeared most 
clearly in the carpal bones and the epiphyses of the 
hand and wrist. Following this suggestive clue, Rotch 
made radiographs, or X-ray pictures, of the wrists of 
two hundred normal children of all ages from birth to 
14 years. From an analysis of the results he marked off 
thirteen stages of anatomical development which he 
designated by the letters A, B, C, D, etc. These con- 
stitute in effect a scale of norms, empirically derived, 
by reference to which we may judge the degree of 
anatomical development which any given child has 
attained. An idea of the scale may be gained by an 
examination of the plates facing this page. 

Rotch finds that anatomical development proceeds 




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PHYSIOLOGICAL AGE 63 

largely independently of height, weight, or chronologi- 
cal age. A 12-year-old child may have a bone develop- 
ment corresponding to that of the average 10-year-old, 
and two 10-year-old boys of equal size may show a 
significant divergence in skeletal maturity. Size and 
real age tell us nothing about a child's anatomical age. 
Rotch presents radiographs of the wrists of three boys, 
aged 7, 8 and 9 years respectively, who are of exactly 
equal skeletal maturity. 

Another important point established by Rotch is 
that girls are more advanced than boys at every age as 
regards epiphyseal development. This is very different 
from that which obtains for height and weight, in ^ich 
traits girls excel boys only from the ages 11 to 14. From 
the plates facing this page we see how much more ad- 
vanced in anatomical age a girl of 5 years may be than 
her twin brother. Twins of the same sex, however, 
always show the same grade of anatomical maturity. 

Diseases which involve disturbances of nutrition 
influence anatomical and physiological maturity much 
more than they affect height or weight. The effect of 
the hookworm disease is shown in another of the plates 
facing this page. 

Physiological age 

The differences which have been discovered in 
physiological, or functional, maturity corroborate in a 
striking way the findings of Rotch and Pryor. For five 
years Crampton collected data on the age at which the 
various stages of pubescence ^ appeared in high-school 
1 Three fairly definite stages were determined. 



64 THE HYGIENE OE THE SCHOOL CHILD 

boys of New York City; These he correlated with 
measurements of height, weight, grip, and school suc- 
cess. Records were secured from 3835 boys of all ages, 
grades, and social classes represented in the schools. 
The results show astonishing differences of physio- 
logical maturity in boys of the same chronological age 
and the same school class. The average high-school 
class, particularly in the first three grades, is a mixture 
of pre-pubescents, pubescents (those who are under- 





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00 


00 


, 




1 






^^ y »— — — Pubescents, 


S 


50 


' 


^^ / ,; Post-Pub.^ 


s 






^w / 


P4 


40 


• 


\f 




30 


■ 


7^^^"\--.... 




20 


/ 


/ ^^^^ 




10 












" . Ill . . . ^ — ^~~, ^"*— •. 


Age Group 


12.25 


12.75 13.26 13.75 14.25 14.75 15.25 15.75 16.25 10.75 17.25 17.75 18.25 


Pre-Pub.^ 


(81) 


69 55 41 26 16 9 5 2 10 


PubescentB^ 


(10) 


25 2G 28 28 24 20 10 4 4 2 


1 Post-PubX 


(2) 


G 18 31 46 60 70 85 93 95 98 100 100 



FIG. 6 

Percentage of each Pubescence Sub-Group for each Half -Tear Group. 

American Physical Education Review, March, 1908. 



• Crampton, 



going the pubescent transition, which lasts usually from 
five to seven months), and post-pubescents. The fun- 
damentally important question which Crampton raises 
is whether the instruction meted out to such a non- 
homogeneous group can possibly be fitted to the intel- 
lectual interests, the moral standards, the sesthetic 
appreciations, or the mental and physical endurance of 
each individual pupil. 



PHYSIOLOGICAL AGE ' 65 

The distribution of the three stages of pubertal 
development in Crampton's 3835 boys is shown in 
Fig. 6. 

The above curves show that 17 per cent of the boys 
whose ages fall between 12 and 121 years have already 
entered upon the pubertal transition, and that by 14 
years the number has increased to 70 per cent. Fur- 
ther, that about 4 per cent of the boys have completed 
the transition by 12i years, and by 15^ years, about 
80 per cent. At 13f years, or about the beginning of 
the high-school period, the number of pre-pubescents, 
pubescents, and post-pubescents is almost exactly 
equal. * 

The second principle established by Crampton is 
that height, weight, and strength correlate much more 
closely with physiological than with chronological age. 
Boys of 14 years, for example, are tall or short, heavy 
or light, strong or weak, according as they have or 
have not reached pubescence. This is shown in the fol- 
lowing significant tables : — 







TABLE 5 










Weight according to physiological age 


(kilograms) 


Age in 
13- 
14 
15 


years 
-14 
-15 
-16 


Pre-pub. 
34.9 
35.7 
37.5 


Pub. 
37.7 
38.7 
39.5 




Post-pub. 
43.9 
46.3 
48.5 



TABLE 6 

Weight of m to 15 year boys according to maturity 

Pre-pubescents 36.76 kilograms 

Pubescents 38.86 ^ 

Post-pubescents [^47.21 , 



66 THE HYGIENE OF THE SCHOOL CHILD 

The results are similar to the above for height and 
strength. We may say, therefore, that boys of 13 
who are post-pubescent resemble in height, weight, and 
strength post-pubescent boys of 15 or 16 much more 
closely than they resemble pre-pubescent boys of their 
own chronological age. In deciding the boy's fitness for 
a given athletic sport, or for a certificate permitting 
him to leave school to work in a mill, or even for in- 
struction of a given grade, the crucial question is not 
how long he has lived, but how far he has proceeded 
toward maturity. Furthermore, in judging the growth 
status of an individual boy the question is not whether 
he is as tall, as heavy, or as muscular as the mathe- 
matical average of boys in general for his age, but 
whether he has reached the physical standard which 
his own actual degree of maturity calls for. 

Scholarship, also, seems to be correlated with degree 
of maturity. Young pupils who have reached an ad- 
vanced grade are likely to be found post-pubescent, 
while old pupils in the lowest grade are often pre- 
pubescent. Of the 14 to 14j-year-old boys in the first 
term (each year is divided into two terms), 42.9 per 
cent are pre-pubescent, while of boys of the same age 
who have reached the fourth and fifth terms, only 16.7 
per cent are pre-pubescent; 68.2 per cent of the 13 to 
13| year boys in the first term are pre-pubescent, as 
against 30 per cent of the same age group who have 
reached the third term. Again, when the percentage 
of failures was calculated for each age according to 
degree of maturity it was found that 50 per cent more 



PHYSIOLOGICAL AGE 67 

of the pre-pubescent 13-year-old boys "failed" than of 
post-pubescent 13-year-olds. The corresponding dif- 
ference for 14 years was 41 per cent, and for 15 
years, 24 per cent. 

Crampton was able to demonstrate what previous 
statistics had indicated but not established; namely, 
that the later the pubescent transition arrives the more 
rapidly it is hurried through. The speed of transition 
from pre- to post-pubescence was also found to be much 
more rapid in summer than in winter, a fact which 
demands reinterpretation of such data as those of 
Malling-Hansen on seasonal variations in growth. 

In a preliminary investigation of physiological age 
differences among high-school girls, Crampton found 
the same relation of physiological age to height, weight, 
and strength as obtained for boys. 

Finally, in a third investigation of dentition among 
934 pupils of the elementary schools, Crampton finds a 
similar correlation of weight, height, and strength with 
the number of permanent teeth which have erupted. 
If further data should confirm this, dentition would be 
found the most serviceable index of physiological ma- 
turity, both because of the ease with which observa- 
tions may be taken and because of the long period 
through which the changes may be noted. 

Conclusions 

The importance of the distinction between physio- 
logical age and chronological age is obvious. We have 
lately awakened to the fact that each year one child in 



68 THE HYGIENE OF THE SCHOOL CHILD 

six or seven fails of promotion; that the large majority 
drop out before reaching the high school; that the 
wholesale elimination involves boys to a greater extent 
than girls; that girls of a given age make better marks 
in their class work and in examinations than boys of 
the same age; that many weakly pupils break down in 
the effort to keep up with the class in which their 
chronological age places them; — that education from 
bottom to top needs more than anything else to be 
individualized. 

It is easy enough to say that this should be our ideal; 
but how to suit the instruction to the individual child 
is anything but easy. The value of such investigations 
as those cited above lies in the suggestions they offer 
in this line. They show that children of the same age 
vary more in maturity than we have ever suspected, 
and that, although the differences are accentuated at 
early adolescence, they are often very marked in child- 
hood. They suggest that girls may possibly be as ripe 
for school at 5 years as boys are at 6, and that they 
normally reach the high-school age some two years 
ahead of their brothers. The entire problem of the 
identical co-education of the sexes will have to be re- 
viewed in the light of this fundamental physiological 
fact. 

The investigations suggest that determinations of 
physiological and anatomical age by the Roentgen 
method, or some other, might well be invoked to help 
decide doubtful cases of promotion. For example, 
let us imagine two girls in a fourth-grade class who are 



PHYSIOLOGICAL AGE 69 

a little slow in their work and about the advisability 
of whose year-end promotion the teacher is in some 
doubt. Both pupils, let us say, are not so low in their 
marks but that they might be expected, with consider- 
able extra effort, to carry the work of the following 
grade if promoted. But would it be wise to have the 
child risk the extra effort this would require.^ We can- 
not answer this question on the basis of weight, height, 
grip, or the presence or absence of external physical 
defectiveness. But if radiographs should reveal that 
one of the girls is a year ahead of her age in the physio- 
logical development and that the other is a year in 
retard, there would then be little doubt about tte wis- 
dom of risking promotion in the former case and deny- 
ing it in the latter. A few years hence may see the 
installation of the Roentgen apparatus in the hygiene 
departments of all cities where school medical supervi- 
sion is practiced. The purpose of such work would not 
be merely that of holding back the weak and imma- 
ture to save them from over-pressure; it would be 
equally concerned about permitting those of advanced 
development to profit by the advantage of maturity 
with which nature has endowed them. 

It is well to emphasize, however, that we do not yet 
know the precise degree to which either pubertal or 
skeletal development is correlated with brain develop- 
ment or with vitality. The relation seems to be, on the 
whole, a fairly constant one, although Rotch himself 
admits possible discrepancies. 

Closer investigation of the relations existing be- 



70 THE HYGIENE OF THE SCHOOL CHILD 

tween the anatomical, physiological, and mental ages 
is one of the urgent problems of educational hygiene. 
We want to know what the best index of general de- 
velopment is. Theoretically, Rotch's method would 
seem to offer the best approach, since skeletal develop- 
ment is probably much less influenced by accidental 
circumstances of training, exercise, environment, etc., 
than are the various physiological functions. Yet 
nothing may safely be taken for granted in dealing 
with matters as complicated as growth phenomena are 
known to be. 

When reliable standards for determining develop- 
mental stages have been worked out they can be put to 
immediate use in diagnosing athletic fitness, in voca- 
tional guidance, in the classification of pupils for man- 
ual work and gymnastic training, etc., as well as in 
problems relating to gradation for purposes of instruc- 
tion. Society has no moral right to turn over the 
weakly immature child of 14 to the overtaxing work of 
mill and factory on the mere basis of so many years 
lived. 

Other problems which suggest themselves are the 
bearing of physiological age differences on moral edu- 
cation, procedure in criminal law, the relative value 
of male and female teachers for various school grades, 
the advisability of instituting the intermediate high 
school, etc. In the light of the well-known changes 
wrought by adolescence in the child's interests, and the 
complete transvaluation which then becomes apparent 
in his attitude toward social and moral questions, we 



PHYSIOLOGICAL AGE 71 

may well ask whether the same instruction can ever be 

suited to the needs of both pre- and post-pubescents 

whom our educational lockstep so frequently chains 

together. 

REFERENCES 

1. Rose Chiles: "The Regeneration of Child Life by Means of the 
Roentgen Ray." The Forum, August, 1910. 
\*2. Dr. C. Ward Crampton: "Physiological Age." Amer.Phys.Ed. 
; Rev., March to June, 1908. 

3. Dr. C. Ward Crampton: "Anatomical or Physiological Age 
versus Chronological Age." Ped. Sem., 1908. 

4. Dr. C. Ward Crampton: "The Influence of Physiological Age 
upon Scholarship." The Psychological Clinic, 1907, pp. 115-120. 

5. J. W. Pry or: Bulletins of the State College of Kentucky. 
1905: "Development of the Bones of the Hand," pp. 30. 
1906: "Ossification of Epiphyses of the Hand," pp. 35. 
1908: "The Chronology and Order of Ossification of the Bones 

of the Human Carpus," pp. 24. ^ 

6. Dr. T. M. Rotch: "School Life and its Relation to the Child's 
Development." Amer. Jour. Med. Sci., 1909, pp. 702-11. 

*7. Dr. T. M. Rotch: "Roentgen-Ray Methods applied to the 
Grading of Early Life." Am. Phys. Ed. Rev., June, 1910. 

8. Dr. T. M. Rotch: "Conditions pertaining to the Safeguarding 
of Early Life from a Pediatric Point of View." N.Y. Med. 
Jour., June 18, 1910. 

9. Dr. T. M. Rotch: "The Development of the Bones in Early 
Life studied by the Roentgen Method." Trans, of Assoc, of 
American Physicians, 1909. 



CHAPTER VII 

DISORDERS OF GROWTH AND THE HYGIENE OF 

POSTURE 

Written with the assistance of Dr. E. B. Hoag 

Disorders of growth affect chiefly the bony skeleton 
and the muscles which support and propel the body. 
The defects most commonly observed may be classi- 
fied as follows : — 

A. Curvatures of the spine. 

1. Kyphosis. (Outward curvature: round back.) 

2. Lordosis. (Inward curvature.) ' 

3. Scoliosis. (Lateral curvature.) 

B. Other deformities. 

1. Pigeon-breast. 

2. Knock-knee and bow-legs. 

3. Flat-foot. 

The human race in the course of evolution has only 
imperfectly adapted itself to the upright posture. For 
this reason, chiefly, deformities of the vertebral col- 
umn, pelvis, and legs are relatively common, since 
these are the structures most affected by the shifting 
of the center of gravity which was brought about by the 
assumption of the upright posture. Naturally, the in- 
fluence is greater during the early periods of life when 
the tissues are soft and subject to various nutritional 
disturbances. The diseases which are particularly 



DISORDERS OF GROWTH 73 

likely to affect the nutrition and growth of the build- 
ing material of the body during the rapid period of 
growth are rickets and tuberculosis. 

Spinal curvature 

Spinal curvature ranks with eye defects as one of 
the most common abnormalities found among school 
children. It is safe to say that from 20 to 30 per cent of 
the entire enrollment are affected, or between four and 
five million in the schools of the United States. When 
the slighter departures from symmetry are included, 
the number runs very much higher. Probably as many 
as 3 to 5 per cent have spinal curvature in a i(^m. se- 
vere enough to menace general health. 

One of the best studies is that of Beholder, Weith, 
and Combe of 2314 school children of Lausanne. This 
showed 24.6 per cent with lateral curvature, 5.8 per 
cent with kyphosis or lordosis, and about 24 per cent 
with flat-foot. In the case of 11.24 per cent, the lateral 
curvature amounted to a spinal displacement of one 
centimeter or more. There was little difference be- 
tween girls and boys. 

Dr. Canavan found the following deformities among 
2333 supposedly normal women students of Wellesley 
College : — 

TABLE 7 
Percentages of orthopedic defects 

1. Back, curvature 35 per cent 

2. Shoulders, uneven , 53 

3. Hips, uneven 43| 

4. Legs 

(a) Knock-kneed 21 



74 THE HYGIENE OF THE SCHOOL CHILD 

(6) Bow-leg 8| per cent 

(c) Unequal f 

5. Ankles pronated 70| 

6. Longitudinal arches 

(a) Flat 12 

(6) High 5 

7. Anterior arches, flat 11§ 

8. Toe joints enlarged 3j 

The results of other important investigations are 
presented in the following table : — 

TABLE 8 









Spinal curvatures of all kinds 


Author 


Place 


Number of 
children 


















Boys 


Girls 


Total 


Krug .... 


Dresden 


1418 


26% 


22.5% 


25% 


Hagman . . . 


Moscow 


1664 girls 


— 


29 




Kallbach . . . 


St. Petersburg 


2333 girls 


— 


26 




Key ... . 


Stockholm 


3000 


— 


— 


10.8 


Guillaume 


Neuchatel 


731 


18 


41 


29 


Silfwerskiold 


— 


7234 girls 


— 


9.9 


17 


Bruner . . . 


— 


1081 boys 


17.1 accord- 
ing to age 






R. T. Mackenzie 


Toronto 


160 high- 
school girls 


— ' 


19 (scoliosis 
alone) 




E. T. Mackenzie 


Toronto 


200 college 
boys 


24 (scoliosis 
alone ) 






R. T. Mackenzie 


Toronto 


446 college 
athletes 


19 (scoliosis 
alone) 






Miss Campbell 


London 


High-school 


— 


22.8 (scolio- 








girls 




sis alone) 





One should be careful, however, to distinguish be- 
tween true spinal curvature and a mere faulty attitude 
due to carelessness or to uncertainty of posture. In 
young children under ten the muscles are sometimes so 
weak that there is not sufficient muscular control to 
keep the spine rigid, in which event it often exhibits a 
convex curve to the right or left. Permanent curvature 
is designated as "fixed" or "anatomical," to distin- 
guish it from the "postural" or 'Afunctional." Prob- 



DISORDERS OF GROWTH 75 

ably in less than half of the cases listed as spinal curva- 
ture has actual deformity of the bones taken place, and 
in not all of these is displacement sufficient to produce 
serious injury. 

Spinal curvatures sometimes begin in early child- 
hood, but more frequently between school entrance 
and puberty. Of 1000 cases analyzed by Roth, 89.7 
per cent first became evident between 5 and 17 years, 
and 59.4 per cent between 10 and 15. Silfwerskiold 
finds 10 per cent affected in the first grade; the number 
rising to 17 per cent in the fourth grade; then dropping 
to 9.9 per cent. The Lausanne investigation gave the 
following distribution according to age: — % 





TABLE 9 






Boys 


Girls 


8 years 


7.8 


9.7 


9 


16.7 


20.1 


10 


18.3 


21.8 


11 


24.2 


30.8 


12 


27.1 


30.2 


13 


26,3 


37.7 



Kyphosis {outward curvature of the spine) 

This condition presents a round back, and involves 
part or all of the vertebral column. Sometimes there 
is a sharp angle formed, especially in Pott's disease. 
The region usually involved is the dorso-lumbar. The 
condition is most common in young rickety children, 
although it may occur in later life as the result, usu- 
ally, of tuberculosis. The common form of kyphosis 
found in school children is known as "round shoul- 
ders." In this the outward curve is usually most 



76 THE HYGIENE OF THE SCHOOL CHILD 

pronounced in the middle of the dorsal pari of the 
spine. 

Usually from 5 to 10 per cent of school children have 
round shoulders. The principal cause is muscular 
weakness which allows the spinal column in this region 
to bend outward, the pelvis to drop backward (lower- 
ing of the posterior part of the pelvis), and the shoul- 
ders to drop forward and downward. It is easier for 
the weak child to assume the positions described than 
to maintain the normal posture, and he does so with the 
result that kyphosis becomes permanently established. 

Muscular inactivity is the most important factor in 
the causation of round shoulders, and in treatment the 
chief aim should be to strengthen the muscles of the 
shoulders, back, and pelvis by appropriate gymnastic 
exercises. 

Simple exercises for the correction of kyphosis 

(1) Bending the trunk forward and backward. 

(2) Breathing exercises. 

Standing in an erect position the child forces the air 
out of the lungs and at the same time the arms are 
brought forward. The arms are then gradually carried 
backward, while at the same time the child rises on his 
toes and takes a long breath. 

(3) Walking exercises. 

These should be taken with special attention to the 
proper erect posture, the hips retracted, the shoulders 
back, and the chin elevated. 

Exercises with pulley weights while the child is seated 







e-te iS 









.2 ^ 



be 

2 




"3 l^ 



a -^ 







C5 



DISORDERS OF GROWTH 77 

at a distance of about three feet are also useful. Mas- 
sage is excellent, and vigorous outdoor exercise is 
indispensable. 

The use of braces in cases of round shoulders should 
nearly always be avoided. No ordinary commercial 
shoulder brace is reliable, and every such brace re- 
strains the action of the muscles. No brace of any 
description ought to be used without the advice of 
an orthopedic surgeon. The latter will rarely prescribe 
one except under special and unusual conditions. What 
the back and pelvic muscles need is not restriction but 
increased exercise and activity. 

Lordosis {inward curvature of the spine) % 
This deformity is not met so often in school children 
as kyphosis and lateral curvatures. It is caused usually 
by some form of hip- joint disease or by dislocation. 
The spinal column in lordosis curves inward. The cor- 
rection consists in the discovery and removal of the 
cause, and for this purpose the advice of a skilled sur- 
geon is always necessary. 

Scoliosis (lateral curvature of the spine) 
Lateral curvatures may be single (to one side or the 
other), or there may be two or three lateral curves. The 
single curvatures are found most frequently in young 
children of about 4 to 8 years of age. " Lateral com- 
pensatory curvatures appear usually at the upper or 
lower end of the primary curvature." Lateral curva- 
ture not only affects the spine, but also the trunk; con- 
sequently the hip projects on the concave side (high 



78 THE HYGIENE OF THE SCHOOL CHILD 

hip). The shoulder on the same side is usually held 
higher than the other (high shoulder). 

Injuries produced hy spinal curvature 

The significance of spinal curvatures does not lie 
chiefly in its interference with the beauty and sym- 
metry of the body, although this is a matter well 
worthy of our consideration. In severe cases the crowd- 
ing and displacement of internal organs may affect 
unfavorably the general health of the body. The organs 
most concerned are the lungs and heart. The crowded 
portions of the lungs fail to develop, and susceptibility 
to pulmonary tuberculosis is increased. Affections of 
the apices (usually the right apex) of the lungs have 
been found in as high as 73 per cent of scoliotic pa- 
tients. Adhesions of the pleura are a frequent result. 
The heart is "pushed upward and pressed against the 
anterior chest wall." Since the breathing is superficial, 
the heart must push a larger amount of blood through 
the lungs in order to secure for the body an adequate 
supply of oxygen. This extra demand on the heart 
results often in its hypertrophy. The course of the 
aorta is somewhat altered and the blood pressure 
undergoes changes. The contents of the abdomen are 
crowded downward, and the transverse colon may be- 
come almost vertical. The liver, kidneys, spleen, and 
stomach all suffer displacement, often with conse- 
quent injury to health.^ 

As regards the relation of the school to spinal cur- 
^ See reference 11, pp. 89-90. 



DISORDERS OF GROWTH 79 

vature, expert opinion has undergone a radical change 
in recent years. Noting the fact that a large majority 
of cases develop between the ages 6 to 14 years, and 
coupling this with the undeniable frequency of incor- 
rect postures in the school, authorities were formerly 
inclined to lay the blame mostly upon school life. La- 
ter studies, however, show that the fundamental cause 
of nearly all severe spinal deformities is to be found in 
an abnormal or diseased condition of the bones. In- 
correct postural habits are an aggravating factor and 
may cause minor curvatures, but they are seldom, if 
ever, the sole cause of grave deformity. These are often 
present in children who have never attended School. 
Nevertheless it is the duty of the school to do every- 
thing in its power to prevent the development of the 
defect in children who are predisposed to it. This is 
possible in various ways. 

The most frequent cause of osseous deformity is 
rickets. This disease is a special form of infant mal- 
nutrition affecting chiefly the bones. The age of onset 
is generally between 6 months and 2 years. If severe, 
most of the bones may be affected. The head becomes 
overgrown, the joints large, the ribs are often "beaded," 
and the bones of the legs and trunk may become dis- 
torted under the weight of the body (bow-legs, knock- 
knees, etc.). 

The disease occurs among all classes, but is more 
common among the poor of large cities. Gilmour's 
study of rickets among 6470 English children showed 
the following relation to housing conditions : — 



80 THE HYGIENE OF THE SCHOOL CHILD 

TABLE 10 

Percentage of children 

living in houses of 1 room . 2 rooms 3 rooms 4 rooms 

Rickety children 13.4 " 65.8 18. 2.8 

Non-rickety children 9.5 56.9 20.3 13.2 

Gilmour found evidence of rickets with 23.16 per 
cent of school boys 5 to 14 years of age, and with 
12.05 per cent of the girls. It is safe to say that in any 
school population, not far from 10 per cent have been 
affected. It is this fact, chiefly, which accounts for the 
prevalence of spinal curvature, knock-knees, bovs^- 
legs, pigeon-breast, etc. 

The mental condition of rickety children averages 
slightly below par, as shown by the statistics of Gil- 
mour. The difference, however, is decidedly less than 
some authorities have claimed. Many rickety children 
are extremely intelligent. 

Tuberculosis of the bone is another frequent cause 
of deformities. The parts most often attacked are the 
spine, hip, and knee.^ If deformity is to be prevented, 
it is essential that treatment be begun at the earliest 
possible moment. It is stated by the 
best authorities that in 95 per cent of 
^ ' * the cases of tuberculosis of the bone, 
deformity has set in before a diagnosis 
has been made. 

Uneven length of the extremities, 
Tracing^^tLting a whether Congenital or caused by dis- 
ingfrom^^everex- ^asc or accidcut, nearly always results 

tremities. (After . ■ i • i i_ ' i_i 

Mackenzie.) m greater or less spmai curvature, witn 

deformity of the hip and shoulder. 

J See p. 136. 



DISORDERS OF GROWTH 



81 



y Postural causes, though not nearly as influential 
as opinion formerly held, are nevertheless import- 
ant. Standing on one leg, if habitual, has some- 
thing of the same effect as uneven extremities. 

Eye and ear defects 
often result in bad pos- 
ture, and therefore fa- 
vor the development of 
spinal curvatures. Myo- 
pia tends to cause round 
shoulders because of the 
effort to get the eyes near 
the book. Astigmatism 
causes functional lateral 
curvature from the tilt- 
ing of the head to bring 
the vertical strokes of the 
print in the diameter of 
clearest vision. Deafness 
in one ear may cause tor- 
sion of the upper part of 
the spine from the effort to listen with the good ear. 

Desks which are too high, too low, too flat, or too far 
from the seat are sure to result in faulty postures. 
The desk should be adjustable for height, for slant, and 
for sliding backward to afford complete rest for the 
arms in writing. 

Because of the extreme differences in the height of 
children in the same grade, it is essential that the seats 
and also the back-rests be adjustable. Differences of 





FIG. 8 FIG. 9 

One-sided position The correct position 

from standing on for recitation or 

one foot — " hip- prolonged standing 

ping out." (Mo- — one foot in ad- 

sher.) vance of the other. 
(Mosher.) 



82 THE HYGIENE OF THE SCHOOL CHILD 

four or five years in age and of fifteen inches in height 
are commonly found among the children of any class. 
Stecher's measurements of 5000 school children show 
that length of legs bears no constant relation to length 
of trunk; hence there is no constant relation between 
proper height of seat and proper height of desk. Both 
need to be adjusted to fit the individual child (4, pp. 
180/). 

In 1911 some forty-seven cities in the United States 
were in part provided with adjustable desks. Few if 





FIG. 10 
Desk too high. (After Cornell.) 

any cities have a full supply of them, and too often 
school officials neglect to make the necessary semi- 
annual adjustments. Experience shows that most of 
the pupils can be approximately fitted if ten per cent of 
the desks and seats in each room are adjustable, pro- 
vided the remainder are divided among three sizes 
appropriate to the grade in question. 

The handwriting should be vertical, or nearly verti- 
cal, in order to insure good posture. Measurements 
have shown that the average distance of the child's 



DISORDERS OF GROWTH 



83 



eyes from the paper is decidedly less in slant writing 
than in vertical. At the same time, vertical writing is, 
in itself, not a sufficient guaranty of correct posture. In 
all school activities constant supervision of posture 
by the teacher is necessary. The relation of writing 
posture to spinal curvatures — functional curvatures, 
at least — is indicated by the following facts presented 
by Scholder : — 

TABLE 11 



Positions assumed by the children 
in writing 



Spine convex to the left . . 
Spine convex to the right., 



16 



Nature of the spinal curvatures 
found 



Left convex scoliosis. . . . 70.3% 
Right convex scoliosis. . 21.1 



Other postural causes include carrying books ^ or 
papers always on one side, improper handling of the 
child during infancy, the suspension of clothing from 
the tips of the shoulders, piano practice, etc. That im- 
proper postures, when habitual, are an important fac- 
tor in the production of spinal curvature is well evi- 
denced by the ease with which deformities are produced 
artificially. Savage tribes shape the heads of their 
children at will by means of moderately tight bandages. 
The foot of the Chinese woman is another illustration. 
Any type of spinal curvature can be experimentally 
produced in dogs and rabbits by similar methods. 

It is evident, therefore, that if children of abnor- 
mally plastic bones are to be prevented from develop- 
ing spinal curvature, strict attention to posture will be 

^ Books should be left at school. Home study is unnecessary in 
the grades below the high school. 



84 THE HYGIENE OF THE SCHOOL CHILD 

necessary. This, however, is not sufficient. The seat, 
the desk, and the method of writing may be ever so 
ideal, but if the child is kept too long at his lessons, 
or if the muscles of trunk and limbs are weakened by 
too little activity or by malnutrition, a correct posture 
cannot possibly be maintained. It is a dangerous delu- 
sion to suppose that vertical penmanship and adjust- 
able desks are an efficient substitute for frequent re- 
cesses, physical activity, and adequate nutrition. The 
child's body demands change. It will not remain, in- 
definitely, even in the most "comfortable" position. 
The desk is really less important than the program of 
study and play. Mental, as well as physical, fatigue 
induces flabbiness of muscle and the slump of posture.^ 
If spinal curvatures are to be cured or arrested, early 
diagnosis is essential. By the methods of examination 
ordinarily used by school physicians in this country 
the milder cases are usually overlooked. The German 
practice of stripping the child to the waist is much 
better. In case of noticeable departure from body 
symmetry, exact tracings should be made to deter-, 
mine the exact nature and extent of the curvature. 

The treatment of spinal curvatures 

Spinal curvatures can nearly always be improved by 
proper treatment, and postural cases (cases in which 
the bone itself has not become deformed) can be cured 
altogether. Figure 11 shows the improvement possible 
in very severe cases. 

^ See reference to Kemsies on school desks. 



DISORDERS OF GROWTH 85 

Orthopedic exercises may and should be given in the 
public schools for the benefit of children with spinal 
deformities. Special classes are needed for this purpose. 
The work should be done by a specialist in physical 



-^/S 



J 



l^y 



^ J 



n \ ) 



I. 



; 



, ; 1 V 



V. 



FIG. 11 

Four tracings illustrating the progress of an " S " curve under treatment for three 
years. (From Mackenzie's " Exercise in Education and Medicine.") — W. B. 
Saunders Go. 

. ^ 

training, and, wherever possible, should be under the 
general direction of an orthopedic surgeon. 

Following the example of Dusseldorf, Charlotten- 
burg, and Chemnitz, many cities in Germany have 
recently instituted "orthopedic classes" of this type. 
In the first class at Dusseldorf 35 per cent were cured, 
53 per cent were improved, and only 11 per cent failed 
to respond to treatment. The corresponding figures for 
the second class were 51, 34.8, and 1.4 per cent. At 
Chemnitz there was improvement in every case, ac- 
companied by a growth increase of from one to two 
centimeters in excess of that which occurred in other 
children of the same age. 

Classes for this purpose should be small, preferably 
not over twenty pupils, and should meet in the after- 
noon for about one hour daily. To secure the maxi- 
mum results from the special class it is always neces- 



86 THE HYGIENE OF THE SCHOOL CHILD 

sary to enlist the cooperation of parents and teachers; 
the former, in order to insure that the child have suffi- 
cient food, sleep, air, and rest; the latter, in order to 
guard against unsuitable posture during school work. 
So successful have been the pioneer efforts in this 
field, that in 1908 the Prussian Ministry of Education 
issued a circular urging the general adoption of the 
orthopedic class for treatment of spinal deformities. 
According to Rothfeld, who organized the work in 
Chemnitz, a city of 280,000 inhabitants may be ex- 
pected to have 1500 school children who should attend 
such classes. If this is correct, the total number in the 
United States must approximate 860,000. 

Pigeon-hreast 

In pigeon-breast the chest looks as if it had been 
pressed together from opposite sides. This results in a 
decreased diameter of the chest from side to side, and 
an increased diameter from front to back. The chest 
capacity, however, is subnormal. The breast-bone pro- 
jects; hence the names "pigeon-chest," "chicken- 
breast," "keel-chest," etc. 

Pigeon-breast is observed only in children in whom 
there is present some unusual softness of the bones, 
most often due to rickets. It not infrequently follows 
whooping-cough in rickety children. The deformity 
has little or no tendency to become worse during the 
period of growth, and the condition is rarely of serious 
importance so far as the health is concerned. In many 
of the milder forms it disappears without any treat- 




DISORDERS OF GROWTH 87 

ment. In what seem to be serious cases the advice 
of a surgeon should always be had. 

Flat-foot 

The name "flat-foot" is given to a foot that has 
given way under the weight of the body, 
and rolled inward, the muscles of the leg not 
being strong enough to hold the foot in its 
proper position. Other common names for 
this condition are "pronated foot" and 
"broken arch." The foot does not really flat- 
ten out; the arch is not really broken. The ^m. 12 
muscles of the legs have been strained by try-^Yerf^^From 
ing to balance the body's weight (which is "Exer^cise 

carried to the foot by the shin bone) upon and Medi- 
cine.") — w. 
the insecure foundation furnished by the 5- launders 

•^ Co. 

base of the ordinary shoe. The strain being 

too great, the muscles have weakened and the foot 

has rolled inward under the weight of the body. 

By preventing the inward rolling of the foot, we over- 
come the defect. This can be done by fitting a shoe 
that has a proper base, a base that is as wide as the 
foot and that receives all the weight of the body. We 
do not have to support the arch, for the arch is not 
in danger of breaking down ; but we do need to provide 
a proper base. The metal device known as an "arch 
prop," or "instep supporter," is usually unnecessary, 
and used without the advice of an orthopedic surgeon 
it may do injury. 
/ It is the shoe that is at fault, and it is the shoe that 



88: THE HYGIENE OF THE SCHOOL CHILD 



must be corrected. The fault lies in the lack of suflS- 
cient base for the shoe. The arch prop does not correct 
this. When a shoemaker sells arch props to a cus- 
tomer, it is a confession of weakness. It is as if a 
builder sold a house, and after the deal was closed tried 
to induce the buyer to purchase some props or jack- 
screws to hold the house up. 

The shoe worn by a flat-footed person has a char- 
acteristic appearance : the upper is bulged inward over 

the heel and instep; the front 
inner corner of the heel is 
worn off; there are wrinkles 
in the vamp just behind the 
ball; the sole shows the great- 
est wear along its inner half; 
the shank is pressed down 
until its forward end touches 
FIG- 13 the ground at each step, and 

Showing one of the first signs of 
flat-foot,-the outward deflection ^hc stitchcS oftCU glVC awaV 

of the lower end of the tendo 

4e'foS(KS.S"err(From at this point, allowing the 
S,t°™d M^dttoe.^-w.t sole to tear away from the in- 

sole. The gait of a flat-footed 
person is also characteristic. He walks with a stiff 
ankle and with the toes turned out. This is very 
commonly observed in girls between the ages of 16 
to 24. 

Every case of flat-foot is attended with more or less 
swelling of the foot and leg. Because the ankle is held 
stiff, the muscles that move it are not brought into 
action, consequently they do not assist in the return of 




DISORDERS OF GROWTH 



89 





the blood to the larger veins. The blood then dilates 
the veins of the extremities and gives rise to swelling 
in the hollow of the foot, around the ankle, and in the 
leg. With the swelling there is soreness and a bruised 
feeling. The distress is not confined to the foot, but 
may extend to the leg, the thigh, or even the back. 
Most of the so-called rheumatism of the feet and limbs 
is really the swelling, stiffness, 
and pain caused by flat-foot. 

If one foot is worse than the 
other, there will be an uneven- 
ness of the two sides of the 
body. The hip on the weaker 
side will be lower than the other, 
the spine will be twisted, and 
the shoulder on the weaker side 
will be higher than its fellow. 
The level of the body can be 
restored by fitting the feet to 
shoes that will prevent rolling 
inward. While many cases of flat-foot can be com- 
pletely corrected by properly fitting shoes, many 
severe cases require treatment on the part of an or- 
thopedic surgeon. 

Flat-foot in children can usually be recognized by 
the heavy gait, the toes pointing outward to a marked 
degree, and the soles of the shoes wearing out along 
their inner borders. Such children tire easily, complain 
of pain in their legs, feet, or back, and ask to be carried 
after they have walked any considerable distance. The 



(I) (2) 

FIG. 14 
Imprint of (1) arched foot and 
(2) flat foot. The absence of 
impression on the inner bor- 
der of the normal footprint 
at " A " is due to the eleva- 
tion of the foot by the longi- 
tudinal arch. The other arch 
lies across the foot in front of 
this. (After Schmidt.) 



90 THE HYGIENE OF THE SCHOOL CHILD 

following points are important in the prevention of 
flat-foot in children : — 

(1) The child must not begin to walk until he does 
so of his own accord. 

(2) No kind of walking apparatus must be used; all 
of them are alike objectionable. 

(3) The shoes must be broad and must conform to the 
shape of the foot. Sandals are best for young children. 

(4) Neither the toe muscles nor any other muscles of 
the feet may be constricted without weakening them 
and risking the production of flat-foot. 

School physicians, teachers, and school nurses ought 
to give careful attention to this matter of flat-foot 
in children. Too commonly it is allowed to pass un- 
noticed, with the result that as the child grows older 
the symptoms become progressively worse. As dem- 
onstrated by Mackenzie (13), flat-foot can be cured or 
greatly improved by massage, bandaging, stretching, 
and appropriate exercises for strengthening the muscles. 

Brunner (quoted by Burger stein) found over 10 per 
cent of school children with flat-foot. Mackenzie's 
figures showed 217 out of 1000 male college students so 
affected, while Dr. Canavan discovered it in 12 per 
cent of 2333 female students of Wellesley College. It 
is present in a large majority of scoliotic children (76 
per cent of Roth's 1000 cases). About 3.4 per cent of 
the applicants for military service in the United States 
are rejected for this cause.^ 

1 The author is indebted to Dr. E. B. Hoag for the above treat- 
ment of flat-foot. 



DISORDERS OF GROWTH 91 

The education of crippled children 

Too often the crippled child has been left to grow 
up in ignorance. Severe deformity is still sometimes 
regarded as a legitimate excuse for illiteracy. What 
town, village, or rural community but harbors some 
poor unfortunate, unable from deformity to attend 
school, and therefore left to his own devices for educa- 
tion — an object of curiosity and source of amusement 
to those about him.^ Little wonder that under such an 
environment the moral and social instincts sometimes 
suffer along with intelligence, and that the personality 
of the cripple becomes warped. It is our neglec% that 
is responsible for the phrase "the psychology of the 
cripple." 

Society is at last awakening to its educational re- 
sponsibility to crippled children, and public schools for 
them are spreading with great rapidity in Germany, 
England, and America. England, under the leadership 
of Mrs. Humphry Ward, has outstripped all other 
countries in this work. The first public school for crip- 
ples in London was established by the Board of Educa- 
tion in 1899. Since then 23 "invalid centers" have 
been established with an enrollment of 1880 pupils. 
Instruction is provided by the city, while the expense 
of meals is met by the "Crippled Children's Dinner 
Society." Many other cities of England have followed 
the example set by London. 

One of the most famous of the European schools of 
this type is the Danish school for Cripples at Copen- 



92 THE HYGIENE OF THE SCHOOL CHILD 

hagen. The school is supported by state grants, and 
combines a residential school, a hospital department, 
a day school, and an "out-patient" department. 
Emphasis is placed on vocational training. The trades 
taught include woodworking, brush-making, bookbind- 
ing, needlework, boot-mending, saddlery, leatherwork, 
etc. 

The first public school for cripples in the United 
States was opened in New York as late as 1906. Since 
then 23 special classes have been formed as a regular 
part of the day-school system of that city. In all, about 
450 pupils are enrolled. Twenty pupils are allotted per 
teacher, and the school day is four hours in length. 
Children who are able to do so come to school in street- 
cars; others are transported in various ways. The ex- 
penses of transportation, nurse attendance, etc., are 
met by the "Guild for Crippled Children." 

In 1911 Chicago had two schools for crippled chil- 
dren with an attendance of 195. Massachusetts is the 
only State which supports an institution for the care 
and education of crippled children. This was estab- 
lished in 1907. 

Though the beginning of this interesting movement 
is rich with promise, much remains to be done. It is 
estimated that in Germany there are 100,000 crippled 
children eligible for this type of school. Of these, 
50,000 are in need of permanent homes. But in all 
Germany not quite 4000 cripples are provided for in 
the public schools. Of the 150,000 or more crippled 
children in the United States, not 1000 are enjoying 



DISORDEKS OF GROWTH 93 

the public-school advantages to which all are enti- 
tled. 

Few lines of educational endeavor are more profit- 
able than special schools for cripples. Nearly all crip- 
ples may be made self-supporting and rendered cap- 
able of leading happy and useful lives. The child is not 
only taught a suitable trade, but his whole life is broad- 
ened and enriched. Intellectual interests and normal 
contact with other children save him from the empti- 
ness and pettiness of the ordinary cripple's life, and the 
saving grace of work transforms him. 

In the education of cripples a word of warning would 
not be out of place. Hand training should not too 
much replace mind training. The physically handi- 
capped may, by perseverance, be taught miracles of 
muscular skill; but economy lies in a maximum culture 
of the crippled child's best faculties. These, very often, 
are mental. The greater the weakness of the body, the 
more dependent is the child upon the exercise of his 
mental powers. 

Attention, finally, should be called to the need for 
public residential schools for cripples, such, for ex- 
ample, as that supported by the city of Manchester, 
England. This school is primarily for the benefit of 
crippled children for whom prolonged surgical and 
hospital treatment is necessary. The patients, who 
number about sixty, are chiefly sufferers from rickets, 
infantile paralysis, or tuberculosis of the bone. 

In many cases of deformity, particularly that result- 
ing from infantile paralysis, regular treatment may 



94 THE HYGIENE OF THE SCHOOL CHILD 

have to be continued for years. Generally it is impos- 
sible to insure that the treatment will be rightly carried 
out in the home. Nor is it just to the child that his 
mental powers should be allowed to atrophy while his 
body is being put in condition. The Manchester school 
combines all the advantages of the children's hospital 
with those of a regular school. The hours of instruction 
are from 9.30 to 12 and from 1.30 to 3.30. Most of the 
time is spent in the open air. The instruction is largely 
vocational. The average length of stay is two years, and 
the cost per child is less than $200 per year. Since the 
school was established in 1905, 98 children have been 
sent out, most of them so improved as to be able to 
enter regular classes or to take a secure place in the 
industrial world. The official report states that rick- 
ety, distorted cripples, unable to walk, are discharged 
after two or three years with sound, straight limbs 
requiring no artificial support and showing no tendency 
to relapse. There are yet no residential schools of this 
type supported by any municipality in this country, 
although it is said there are 18,000 children in the city 
of New York alone undergoing prolonged treatment 
in children's hospitals. 

The obligations of society to the crippled child are 
perfectly clear, and the educational activities we have 
just sketched are of the greatest promise. The move- 
ment should continue until the educational rights of 
crippled children are everywhere recognized and given 
first claim to attention. 




A VERY SERVICEABLE TEST FOR POSTURE 

Prom Bancroft's "Posture of School Children," by permission of The Macmillan Com- 
pany, New York. 



DISORDERS OF GROWTH 



95 



TABLE 12 

General survey of leading deformities 



Kyphosis 


Lordosis 


Scoliosis 


Flat-foot 


(outward curvature) 


(inward curvature) 


(lateral curvature) 


Signs 


Signs 


Signs 


Signs 


Round back 


Back curving in- 


Inequality in 


Ankle turned 


Round shoulders 


ward 


height of 


inward 


Angular projection 


Protruding abdo- 


shoulders 


Shoe heel worn 


in the dorso-lum- 


men, (Often 


One hip higher 


out on inner 


bar region 


present with 


than the other 


side 


Wing shoulder 


kyphosis) 


Wrinkling of 


Stiff, inelastic 


blades 




clothes on one 


gait 


Flat chest 




side of the 


Toes turn out- 






back 


ward in walk- 
ing 
Barefoot-track 
test 


Causes 


Causes 


Causes 


Causes 


Muscular weakness 


Hip-joint disease 


Weak muscles 


% 
Muscular 


Rapid growth 


Dislocation of hip 


Malnutrition' 


weakness 


Rickets 


Rickets 


Rickets 


Improperly fitting 


Tuberculosis of spine 




Tuberculosis of 


shoes 


Forward posture in 




spine or hip 


Jumping 


school, etc. 




Some form of 
paralysis 








Faulty postures 





REFERENCES 

1. Gladys Abbott: "A Study of Posture in School as afiFected by 
Schoolroom Lighting." Am. Phys. Ed. Rev., March, 1905. 
*2. Jessie H. Bancroft: The Posture of School Children. 1913, pp. 
327. 

3. Dr. Biesalski: "Was konnen die Schularzte zur Behandlung 
der skoliotischen Volksschulkinder tun ? " Zt.f. Schulges., 1906, 
pp. 545-50 and 610-27. 

4. W. S. Cornell: The Health and Medical Inspection of School 
Children. 1912, pp. 461-78. 

5. R. C. Elmslie: "Minor Defects of Adolescence in Relation to 
Medical Inspection." School Hygiene. 1910, pp. 616-30. 

6. A. Gilmour: "Mental Condition in Rickets." School Hygiene, 
1912, pp. 6-16. 

*7. J. E. Goldthwaite: Relation of Posture to Human Efficiency. 

Boston, 1909, pp. 38. 
8. J. E. Goldthwaite: In Pyle's Personal Hygiene, fifth edition. 
. 1912. (Chapter on "The Body-Posture.") 



96 THE HYGIENE OF THE SCHOOL CHILD 

9. Fritz Hartel: "Die Skoliose eine Volkskrankheit." Inter. Mag. 
Sch. Hyg., vol. iii, 1907, pp. 324-54. 
10. Dr. Leonard: "Das Orthopadische Turnen in die Schule." Zt.f. 
Schulges., 1910, pp. 713-24 and 807-13. 
*11. R. W. Lovett: Lateral Curvature cf the Spine and Round Shoul- 
ders. 1907, pp. 188. New Edition, 1912. 
12. R. W. Lovett: "Relation of School Life to Lateral Curvature of 
the Spine." Proc. 1912 Cong. Am. Sch. Hyg. Assoc, 1912, pp. 
174-79. 
*13. R. Tait McKenzie: Exercise in Education and Medicine. 1910, 
pp. 406. (Especially chapters xv to xviii.) 
14. Eliza Mosher: Health and Happiness; A Message for Girls. 1912. 
*15. Eliza Mosher: "Habitual Postures in School Children." Ed. 
Rev., 1897, pp. 261-72. 

16. George Muller: Spinal Curvatures and Awkward Deportment. 
London, 1894, pp. 88. (Chiefly of historical value.) 

17. Bernard ^oth: Treatment of Lateral Curvature. Second edition, 
1899, pp. 141. (Chiefly of historical value.) 

18. Dr. Rothfeld: "Funf Jahre orthopadisches Schulturnen in 
Chemnitz." Zt. f. Schulges., 1911, pp. 249-62 and 344-56. 

*19. Scholder, Weith, and Combe: "Les deviations de la colonne 
vertebrale dans les ecoles de Lausanne." Jahrb. der Schweizer- 
ischen Gesellschaft f. Schulhygiene, 1901. 

20. Dr. Schulthess : Schule u. RUckgratsverkriimmung. Voss, Leipzig, 

1902. 

21. J. S. Kellet Smith: "Lateral Curvature and Short Leg." The 
Child, 1913, pp. 411-17. 

22. F. Wohrizck: "SonderschulenfiirSkoliotische." Zt.f. Schulges., 
1907, pp. 175-79. 

23. (See Standard texts on School Hygiene: also on Children's 
Diseases.) 

The education of crippled children 

24. Konrad Biesalski: "Kriippelschulen." Zt. f. Schulges., 1911, 
pp. 411-21. 

25. R. C. Elmslie: The Care of Crippled and Invalid Children in 
Schools. Not dated, pp. 50. School Hygiene Pub. Co., London. 
(Very valuable.) 

*26. Evelyn M. Goldsmith: "The Education of Crippled Children." 
In Monroe's Encyclopedia of Education. 1912, vol. ii. 
27. D. C. McMurtrie: " The Education of Crippled Children in the 
United States." School Hygiene, 1912, pp. 17-23; vol. iv, pp. 
129-62. 

*28. Leonard Rosenfeld: "IJber Kriippelschule." First Interna- 
tional Congress for School Hygiene, vol. iv, pp. 129-70. 
29. F. Shrubsall: "The Danish Cripple School System." School 
Hygiene, 1912, pp. 172-73. 

*30. E. D. Telford: The Problem of the Crippled School Child. Lon- 
don, 1910, pp. 32. (An account of the Manchester Residential 
School.) 



DISORDERS OF GROWTH 97 

Selected references on school desks 

*31. Leo Burgerstein : In Burgersteiri u. Netolitzky's Bandbuck der 

Schulhygiene, 1912, pp. 62-69. 
*32, F. B. Dresslar: In Monroe's Encyclopedia of Education, 1912, 

vol. II. 
33. Frederick J. Cotton: "School Furniture for Boston Schools." 

Am. Phys. Ed. Rev., December, 1904. (Very valuable.) 
*34. Kemsies u. Hirschlaff: "Arbeits u. Ruhehaltungen in der 

Schulbank." Zt. f. Schulges., 1912, pp. 409-24 and 497-509. 



CHAPTER VIII 

MALNUTRITION IN SCHOOL CHILDREN 

The importance of nutrition 

"Malnutrition" is a much broader term than 
'* starvation." The latter is ordinarily used to desig- 
nate the condition of extreme insufficiency of food. But 
malnutrition is probably half as prevalent among the 
well-to-do as among the poor. A child may be ill-nour- 
ished either because of insufficiency of food, because of 
inherent weakness of the power of food assimilation, 
because of disturbances of the digestive processes, or 
because the food has been improperly chosen or unsuit- 
ably prepared. Accordingly, the educational and other 
sociological aspects of our problem are just as import- 
ant as the economic. 

Nutrition is fundamental for all lines of child devel- 
opment. The stability of the bodily structure is de- 
pendent upon the materials that make it up. Malnu- 
trition during the period of growth leaves permanent 
flaws in the constitution. It is responsible for more 
degeneracy than is alcohol. Alcoholism is often nothing 
but a symptom of disturbed nutrition. The greatest 
problem throughout childhood is that of feeding. 

The influence of food on growth in height and weight 
has already been set forth, and has been shown to rank 
in importance with the influence of race. In the chil- 



MALNUTRITION IN SCHOOL CHILDREN 99 

dren of the poor, puberty is reached late and the pu- 
bertal growth acceleration is slurred over. Resistance 
to infection is markedly decreased. Ill-nourished chil- 
dren "take" everything. Malnutrition is almost the 
invariable forerunner of tuberculosis, chorea, and many 
other diseases. It also renders recovery less certain 
and increases the liability to relapse. 

The effects of severe malnutrition are well illustrated 
by the hookworm disease. The hookworm victim of 
26 years may present a state of sexual and skeletal 
development normal to that of the 14-year-old child. 
Children of 14 years present the general appearance of 
10-year-olds. Growth and development are inttrfered 
with and to an extent proportional to the number of 
the parasites. The disease is extremely prevalent in 
some areas of the Southern States, sometimes from 50 
to 60 per cent of the children being affected. 

The effect of malnutrition on mental development is 
probably very great, though difficult to measure accu- 
rately. Malnutrition is from two to three times as com- 
mon among children who are badly retarded mentally 
as among those making average progress. Plans for the 
feeding of school children have in this country usually 
originated among the teachers of special classes, and 
increased mental alertness is always a marked sequel 
of school feeding. Bean has reported a case of perma- 
nent peculiarity of mental development resulting 
apparently from severe and prolonged malnutrition 
during the pre-school period (3). Dr. Warner found 
from his examinations of 100,000 London school chil- 



100 THE HYGIENE OF THE SCHOOL CHILD 

dren that 28 per cent of the dull pupils were ill-nour- 
ished, and conversely that almost the same percentage 
of the ill-nourished were dull. Macmillan and Bodine 
found that of 2100 retarded children, 54.6 percent were 
suffering from malnutrition. It is probable, however, 
that the mental effects are less marked than the phys- 
ical. The tissues do not suffer equally, but roughly in 
proportion to their importance. Starvation may re- 
duce the weight of the muscles nearly 50 per cent while 
effecting a loss of only 1.1 per cent upon the central 
nervous system (31). The survival value of such an 
arrangement is obvious. 

Are many children ill-nourished? 

In order to estimate the importance of malnutrition 
as a problem in child hygiene it is necessary to gain an 
idea of .its prevalence. But difficulty arises here because 
of the absence of any definite and universally accepted 
criterion. Perfect nutrition gradually shades off into 
slightly unsatisfactory nutrition, and the latter into 
extreme malnutrition. Some medical examiners report 
only the latter; others report all cases which present 
symptoms of subnormality. If this is borne in mind, 
such disagreement as may be found in the statistics 
about to be presented will not be misleading. 

Perhaps the most thorough investigation yet made 
in this country is that of Macmillan and Bodine (9). 
This investigation included an examination of 10,000 
children in one of the poorer districts of Chicago. The 
proportion suffering from malnutrition varied from 



MALNUTRITION IN SCHOOL CHILDREN 101 

nearly 16 per cent among kindergarten children to 
about 6 per cent above the fourth grade. These figures 
avowedly include only the extreme cases. Harring- 
ton's report on the 90,000 school children of Boston 
places the number of anaemic and ill-nourished at ap- 
proximately 5000, or nearly 6 per cent. Of 2000 chil- 
dren examined in certain New York schools, in 1909, 
more than 13 per cent were reported ill-nourished. 
Robert Hunter and John Spargo (40) estimate 
that there are probably 2,000,000 school children in 
the United States suffering from malnutrition. 

The report of the Royal Commission estimated that 
9 per cent of the school children of Aberdeen, S<iotland, 
are under-nourished, and 29.8 per cent of those in 
Edinburgh. Eicholz estimated the ill-nourished school 
children of London at 16 per cent, and Dr. Macnamara 
at 10 to 15 per cent. 

Dr. Crowley, of Bradford, England, classified 817 
school children according to nutrition into three 
classes. The following table represents his results. 
Group A represents pupils from the better districts 
of the city; Group B those from the poorest. 



TABLE 13 



Nutrition 


Infant School 


Upper School 


Group A 


Group B 


Group A 


Group B 


Good 


55% 

36 

29 


31% 

35 

34 


68% 
25 

7 


24% 
43 


Below normal 


Poor or very poor 


33 



102 THE HYGIENE OF THE SCHOOL CHILD 

The following table from Dr. Arkle shows the condi- 
tions of nutrition found among 1026 boys and 921 girls 
in the secondary schools of Liverpool. The columns 
A, B, and C correspond to schools attended by the 
children of the best classes, the middle classes, and the 
poorest classes respectively. 



TABLE 14 





Boys 


GirL 


Nutrition 
















A 


B 


C 


A 


B 


c 


Good 


80. % 


28.5% 


10.5% 


91.6%> 


65.7% 


16.9% 


Fair 


17.8 


60.1 


35.3 


8.1 


33.9 


52.5 


Poor 


1.3 


9.7 


48.6 


0.0 


.7 


28.6 


Very bad. . . . 


— 


.7 


2.4 


0.0 


.0 


1.8 



In Germany, Wimmenauer reports (1912) an excep- 
tionally careful study of the nutrition of 1942 school 
children in Mannheim. His results are summarized 
as follows: — 





TABLE 15 




Nutrition 


Boys 


Girls 


Good 


18.8 per cent 

62.6 

18.6 


31.2 per cent 
55. 


Medium 


Bad 


13.8 







One of the most thorough studies yet made is that of 
Caspar (16) of 8037 children, of Stuttgart, 6 to 14 years 
of age. His procedure was to arrange the pupils of a 
room in a row so as to show a progressive degree of 
paleness. Then he placed by themselves all those whose 



MALNUTRITION IN SCHOOL CHILDREN 103 

color was unsatisfactory, and rearranged this group 
according to thinness. The following classes are then 
distinguished and in the proportions named : — 

TABLE 16 

1. Excellent in all respects 24.6 per cent 

2. Average 32.7 

3. Average nutrition with pallor 17.3 

4. Deficient nutrition without pallor 13. 

5. Deficient nutrition with pallor 12.3 

If groups 4 and 5 are thrown together and group 3 
regarded as satisfactory, we have a total of 25.3 per 
cent ill-nourished. 

Fewer studies have been made in rural schools. Such 
evidence as is available indicates that the proportion of 
ill-nourished is somewhat less than in the large cities, 
but that it is very great. This is further indicated by 
the fact that tuberculous school children are only a 
little less numerous in country than in city schools. Of 
course there are exceptional schools, both rural and 
urban, where few ill-nourished children are to be found, 
but the teacher of forty children may ordinarily expect 
to have anywhere from two or three to eight or ten 
who are below par in nutrition. It would be well for 
her to try to identify them and to correlate her findings 
with their school progress, deportment, nervous con- 
trol, etc. 

The above statistics, which are all based on actual 
medical examinations, thus show that from 6 to 30 per 
cent of the school children suffer from malnutrition. 
The average would seem to be between 10 and 15 per 
cent, at least for cities, throughout western Europe and 



104 THE HYGIENE OF THE SCHOOL CHILD 

America. The number is largest in the earlier years 
and decreases gradually in the upper grades. 

Inadequate feeding as a cause of malnutrition 

Investigations usually show that from 10 to 15 per 
cent of those living in the poorer districts of our large 
cities are inadequately fed. Leckstrecker found that of 
10,707 industrial school children of New York Citjs 
439 had no breakfast, 998 had only coffee and bread, 
and only 17 per cent a satisfactory breakfast; 998 
were ansemic. Harrington found that of the 5043 ill- 
nourished children in Boston, 33 per cent received an 
"unsatisfactory" breakfast. Seventy per cent of Bos- 
ton's poorly fed came from homes classed as well-to-do. 
Of 12,800 children in 16 New York schools who were 
questioned privately by the principals, 7.7 per cent 
had no breakfast, and 15.3 per cent more only bread 
with coffee, tea, beer, etc. A similar investigation in 
Buffalo returned 4.46 per cent as breakfastless and 9 
per cent more as having had entirely too little. Mac- 
millan states that at least 5000 children in Chicago are 
habitually hungry. 

Bernhard ^ found that of 8451 school children of Ber- 
lin, .5 per cent had had no breakfast and 6.8 per cent 
almost none. In Munich, a few years ago, 1557 break- 
fastless school children were found. Christiania, Nor- 
way, had over 3000 ill-nourished school children in 
1901. Of these, 52 per cent had no breakfast, the 
remainder only coffee and bread. In Pavia, Italy, 
^ See Kelynack's Medical Inspection of Schools, p. 374. 



MALNUTRITION IN SCHOOL CHILDREN 105 

January 17, 1900, of 2500 children in four schools, 10 
per cent had come to school without breakfast and 50 
per cent with an inadequate one. In Padua, the same 
year, over 5 per cent had no breakfast and nearly 50 
per cent one that was unsatisfactory. 

Data secured by Dr. E. B. Hoag from 3000 school 
children in the smaller cities and towns of Minnesota 
showed that 65 per cent had breakfast with no proteid, 
85 per cent with no fruit, and 60 per cent without 
either a fruit or a proteid food. 

If the breakfastless child invariably received a satis- 
factory dinner and supper, the situation would not be 
so serious. But investigations show that this is i^ot the 
case. Among families which are either poor, ignorant, 
or neglectful, the noon meal is likely to be even worse 
than the breakfast. In one group of New York's badly 
nourished children, 68 per cent returned at noon to 
homes where no regular noon meal was prepared. In 
two schools where 13.3 per cent of the children were 
ill-nourished, 5 per cent of all the mothers worked away 
from home. In such cases the pennies which are given 
to the children for buying lunches are usually expended 
for the worst imaginable food, — cookies, candy, cream 
puffs, cornucopias, doughnuts, third-grade bananas, 
pickles, etc. The more extreme and chronic the insuffi- 
ciency of nutrition, the more perverted the appetite 
is likely to be. As Spargo has remarked, the craving 
of the ill-nourished child for pickles and other unwhole- 
some articles of food is analogous to that of the alcoholic 
fiend for his favorite beverage. Much of the food thus 



106 THE HYGIENE OF THE SCHOOL CHILD 

purchased by the child comes from street venders and 
other questionable sources, and is likely to be unclean 
as well as unwholesome. 

We must regard inadequate feeding, therefore, as 
one of the important causes of malnutrition. This is 
due sometimes to poverty, but more often to ignorance 
and neglect. The statistics just quoted show this con- 
vincingly, though it is of course impossible to separate 
the influence of poverty, ignorance, neglect, bad hous- 
ing, deprivation from play, sleep, etc. Regularity of 
meals and care in the selection and preparation of the 
child's food cannot be too strongly emphasized, and 
in such matters the parents in comfortable houses are 
often at fault. Children pay the penalty when mothers 
have not been rightly educated. The malnutrition 
problem is therefore about one third economic and two 
thirds educational. Teacher and school doctor should 
not hesitate to inform well-to-do mothers when their 
children are found undernourished, even at the risk of 
giving offense. 

Other causes of malnutrition 

In the case of no other common defect is the degree of 
parental care so great an influence. Investigators find, 
for example, that malnutrition is far less common 
among Jewish than among Gentile children, even when 
the latter are at an economic advantage. Dr. Hall's 
figures show Jewish children in London to be 6 J pounds 
heavier and 2§ inches taller at the age of ten than other 
children in the same schools (11, p. 490). The mor- 



MALNUTRITION IN SCHOOL CHILDREN 107 

tality rate for Jewish children in the first year is de- 
cidedly lower in every country than that for children 
of other peoples. The difference is not thought to be 
due to racial heredity, but to the more general care 
given to infants in the Jewish home. 

Parental neglect and ignorance are often responsible 
for underfeeding, for pampering the child in his food 
habits, and for the use of stimulants such as tea, coffee, 
and alcoholic drinks. The same cause is responsible for 
insufficiency of sleep, over-excitement, and many other 
enervating influences which affect the child's ability to 
digest and assimilate its food. The child thrives not on 
what it eats, but on what it can digest and assin^late. 

Insufficient clothing aggravates malnutrition by rob- 
bing the body of its heat. The child who is scantily 
fed and scantily clothed is compelled to burn his candle 
at both ends. For many a pinchbeck youngster, boots 
and a warm dinner are equally necessary. 

The overwrought, nervous child is nearly always 
ill-nourished, and this in turn aggravates still further 
the nervous instability. Carious, aching, or irregular 
teeth and diseased gums are at the bottom of many 
cases of malnutrition. Adenoids and enlarged tonsils 
induce a condition of general toxaemia which pro- 
foundly affects nutrition. Many cases are traceable 
almost entirely to eye strain, or other reflex nervous 
disturbances, such as those produced by parasites, etc. 
Worry and unhappiness have a similar effect. Rollick- 
ing fun and happiness are essential alike for correct 
physical and for healthy mental growth. 



108 THE HYGIENE OF THE SCHOOL CHILD 

External causes seldom act alone. There are chil- 
dren of robust constitution whose growth momentum 
seems to defy every kind of unfavorable environment. 
There are others whose growth suffers for every trifling 
cause. These are the children whose powers of diges- 
tion and assimilation are feeble by native endowment. 
" Delicate " best describes them. They are often bright, 
nervous, and sensitive to every influence. The com- 
bined efforts of education, medicine, and home training 
are necessary in order to usher such children into 
an efficient manhood or womanhood. With them the 
strenuous life of the school may be but an added bur- 
den. Let the school beware that it cast not its influ- 
ence with the afflictions of evil heredity and stunting 
environment. 

The assimilation of food depends not only on the food 
itself and the soundness of the digestive apparatus, but 
fully as much upon the influences exerted on metab- 
olism by bodily activity. The tissues can starve for 
oxygen in the out-of-doors if the bodily functions are 
not stimulated by exercise. In like manner, the child 
who hugs his books for six or more hours per day may 
suffer malnutrition in the midst of abundance. There 
is no way for the school to atone for the evil it does 
when for a dozen years it assiduously cultivates perni- 
cious habits of sedentary living. 

Identifying the ill-nourished 

The worst cases of malnutrition can be identified 
easily enough by any one whose eye has been trained 



MALNUTRITION IN SCHOOL CHILDREN 109 

to detect unhealthy skin color, thinness of the body, 
undersize, and the symptoms of lassitude. But in the 
case of many children a sure diagnosis is not gained by 
casual inspection. In a field where even the experienced 
school doctor sometimes falls into error, the teacher 
cannot hope to avoid all mistakes. It is believed, how- 
ever, that nothing but good can result from a habit of 
attention to the symptoms most commonly involved. 
In malnutrition the face is not usually thin and 
pinched, but often plump in appearance, and for this 
reason many cases are overlooked. In such cases the 
fat lacks firmness and is not healthy. Often there is a 
fullness under the eyes. The color is usually, Imt not 
invariably, pale.^ The skin is likely to be harsh and 
inelastic, the hair deficient in luster, and the eyes dull 
or "nervous," with pale-blue rings beneath. The 
breath may be foul, with other symptoms of indiges- 
tion. Motor symptoms are common, especially twitch- 
ings of the eyelid and tongue, unsteadiness of body 
balance as shown by Warner's simple tests; and in 
extreme cases movements approaching the choreiform 
may be marked. Stuttering may develop. The child 
usually plays less actively than the average, fatigues 
easily, and sleeps badly. Nightmares, groundless fears, 
and obsessions are common. The child may be either 
apathetic and listless or else abnormally high-strung 
and irritable. Children of the latter type are easily 
worried by school work and develop finical habits. The 

^ The examiner must remember, too, that the color of the skin is 
influenced by the temperature of the room, previous exercise, racial 
heredity, etc. 



110 THE HYGIENE OF THE SCHOOL CHILD 



appetite is nearly always diminished and is likely to 
become freaky. Queer food preferences and violent 
aversions are formed. The best foods are likely to be 
just the ones most disliked. If the parents are un- 
wisely indulgent, the child becomes spoiled. 

Growth may be markedly affected. Height, weight, 
and chest girth are below par in a large majority of 
cases. Measurement of weight alone will disclose many 
cases of malnutrition, as Wimmenauer has shown, but 
because of racial and family differences, this test is too 
unreliable to use as the sole criterion in the individual 
case. Nevertheless, if a large number of children be- 
longing to a fairly homogeneous race are weighed and 
found to average considerably below the weight norms 
for that race, it may be inferred that the group contains 
an undue proportion of undernourished children; also 
that a majority of those falling farthest below the 
norm for their respective ages are undernourished. In 
the experiment already referred to, Wimmenauer class- 
ified 1942 school children according to external symp- 
toms of nutrition and then compared the well-nour- 
ished and the ill-nourished in height and weight. The 
following table shows the average excess in height and 
weight of the well-nourished group over the poorly- 
nourished group for the ages 6 and 9 : — 

TABLE 17 





Boys 


Girla 


Age 


Height 


Weight 


Height 


Weight 


6 to 7 
9 to 10 


5.0 cm. 
6.2 cm. 


3. kg. 
5.5 kg. 


4.4 cm. 
8.0 cm. 


2.8 kg. 
6.3 kg. ■ 



MALNUTRITION IN SCHOOL CHILDREN 111 

Other common growth symptoms, in case the malnu- 
trition is long-standing, are carious teeth, delayed den- 
tition, scoliosis, and rickets. Scoliosis is favored both 

by the less active life and by the muscular weakness. 

. ... V t^M t*'-?"^ 

AKickets is indicated by knock-knees, bow-legs, pigeon- 
chest, beaded ribs, enlarged joints, and sometimes 
retarded mental development. Rickets is not strictly 
a *'bone disease," but a special form of malnutrition 
which has many other results besides that of weaken- 
ing the resistance of the bones. ^ 

It is easy enough to pick out the half-starved horse or 
pig from his well-fed companions, but in the case of the 
child, clothes and tidiness deceive. If the skin o¥er the 
ribs is smooth and well-filled out above and below 
the nipples, nutrition is probably not defective. There 
should be no marked depressions between the ribs. 
According to Wimmenauer (42), if these appear be- 
neath the nipples only, the nutrition may be considered 
"medium, "but if there are deep furrows both above 
and below the nipples, the nutrition is "bad." Wim- 
menauer also suggests that measuring by means of cal- 
iper compasses the thickness of a fold of the skin held 
between the thumb and finger gives a better idea of the 
quality of the adipose tissue than can be gained by 
mere inspection. 

The Oppenheimer formula for the determination of 
nutrition has been extensively employed with school 
children by Schuyten. According to this, the coeffi- 
cient of nutrition equals 

1 See p. 79. 



Il2 THE HYGIENE OF THE SCHOOL CHILD 

girth of arms X 100 i 
chest girth 

The condition of the blood is a valuable index of 
nutrition. The red corpuscles may be deficient to the 
extent of 1,000,000 or more for each cubic millimeter of 
blood, while the hsemoglobin content may run as low 
as 60 per cent. School children should ordinarily have 
a corpuscle count of about 4,500,000 per cubic milli- 
meter, and a hsemoglobin content of about 85 to 90 
per cent. Pre-tuberculous children entering open-air 
schools have usually a hsemoglobin content of 65 to 
75 per cent. This is the reason for the observed pallor 
and helps to explain their high fatiguability and low 
power of resistance to disease. 

So many disorders of childhood are ushered in by 
anaemia that it would be well if every child could have 
two or three blood tests during his school life. Anaemia 
is especially common among girls in the earlier years 
of adolescence. If blood counts were common for the 
high-school girls, teachers might consent to ease some- 
what the burden of work for a year or two in the case of 
many pupils. For the anaemic school child, boy or girl, 
there is no cure short of fundamental reform of nutri- 
tion, and this is possible only through a wisely selected 
diet, active play, sleep, rest, and a happy life. 

Suggestions for identifying the ill-nourished school child 

The teacher cannot hope in many cases to make the 
identification certain. The following, however, are 
1 If nutrition is normal the quotient is at least 30. 



MALNUTRITION IN SCHOOL CHILDREN 113 

some of the common indications of malnutrition. The 
child who shows several of the symptoms named is 
likely to be ill-nourished, and should be referred to a 
physician for examination. 

Is there pallor of skin? 

Is the child extremely thin? 

Are there furrows between the ribs? 

_^ the arm girth (midway between elbow and shoulder) X 100 

Does : — -. — — : — : = 30? 

chest girth (average between expiration and inspiration) 

Is the flesh soft and flabby? 

Is there puflSness under the eyes? 

Is the posture slouchy? 

Does the child appear to lack physical energy? 

Does the child prefer quiet games or books to boisterous 
play? % 

Is the child listless? 

Is mentality slow? 

Is the appetite freaky (lack of appetite, preference for 
highly seasoned foods, etc.)? 

Are there symptoms of nervousness? 

Does the child have frequent headaches? 

Is physical endurance good? 

Does the child take cold easily? 

Is there shortness of breath? 

Is sleep disturbed? 

Are there indications of earlier rickets (bow-legs, knock- 
knees, pigeon-breast, spinal curvature, badly decayed 
teeth, etc.)? 

Are the neck glands enlarged? 

The responsibility of the school 

The first duty of the school is to feed its hungry 

pupils. The oft-heard argument that the school has no 

concern with the child, except to educate him, is now 

an anachronism. In its vocational instruction, play 



114 THE HYGIENE OF THE SCHOOL CHILD 

supervision, moral education, health examinations, 
and medical clinics the school has once for all cut loose 
from its moorings to the "Three R's." The school is 
not an unchangeable entity whose functions are prede- 
termined and limited by definition. It is fast becoming 
the recognized agency for every kind of child-welfare 
work, and the most effective leverage for raising the 
new generation to a higher level than our own. As 
Robert Hunter reminds us, the world and all that is on 
it will soon belong to the children now in our schools, 
and every means is legitimate which can help to make 
them more worthy to possess it. 

Advocates of school feeding are therefore not dis- 
turbed by the cry of "socialism." It is no more social- 
istic than free education, free textbooks, free pencils, 
free playgrounds, and medical inspection. It is no 
more socialistic to heat the child's body internally with 
food than to heat it externally by warming the air of 
the schoolroom (7). 

But is not school feeding a species of paternalism 
which will undermine parental responsibility .^^ Some 
people are obsessed by this pauperization argument. 
Parents did not lose interest in education when the 
State assumed control of it. Health supervision in the 
schools does not make parents negligent of the physical 
welfare of their children. On the other hand, the more 
interest the State displays in its children, the more the 
feeling of parental responsibility is awakened. 

The sad truth is that, too often, the parents of neces- 
sitous children have little parental responsibility to 



MALNUTRITION IN SCHOOL CHILDREN 115 

destroy. The home is a home in name only. The inter- 
ference of the State in behalf of the children of such 
parents is the best guaranty that the parents of to- 
morrow will be different. 

Even if parents were pauperized, school feeding 
would still be necessary. Our first duty is to the chil- 
dren, not to the parents. **No argument, moral or 
economic, can defeat the claims of a hungry child." 
"After bread, education," is the unanswerable slogan 
of the Fabian Society. The State which protects chil- 
dren from cruel beating will sooner or later protect 
them also from slow starvation. 

But why public charity.? Cannot private philan- 
thropy cope with the evil.? The answer is that it is not 
.rightly a problem for charity at all, any more than is ed- 
ucation itself. Children have a right to food, and when 
it is not otherwise forthcoming the State has the 
duty to supply it. If private charity were sufficient 
there would not be so many ill-nourished children. 

Besides, the presence of such children in the school 
interferes with the educative process itself. Malnutri- 
tion makes children dull and retarded. We should 
not expect them to " make brick without straw." To 
feed them is both less expensive and more effective 
than to educate them as defectives in special classes. 
The school has the right to protect itself against the 
non-functioning home. 

The duty of the school is so much the clearer for the 
reason that it is itself one of the causes of disturbed 
nutrition. It imposes upon the child a sedentary life, 



116 THE HYGIENE OF THE SCHOOL CHILD 

instills sedentary habits, confines him in an unhealth- 
f ul atmosphere, and adds the burden of five or six hours 
of mental v/ork which often entails nervous strain and 
anxiety.^ 

Finally, it should not be overlooked that the school 
meal may be made an educational influence of the first 
rank. It offers the very best means of teaching chil- 
dren neatness, cleanliness, and good manners. The 
hygiene of foods, the "balance" of meals, the danger 
of flies, the importance of thorough mastication, and 
the care of the teeth cannot be so effectively taught in 
any other setting. The work of preparing the meal 
offers the highest type of training in social cooperation. 
Some of the ill-nourished school children never sit 
down to a meal in the "home." Only a few regularly 
use a tooth-brush or wash the hands before meals. 
Their parents often have no conception of the food 
requirements of children. 

And these parents were in the public schools a few 
years ago! If the State had not neglected its duty 
then, it would have smaller responsibility now to their 
neglected children. 

The best argument for school feeding is its success 
where tried. For many years most of the cities of cen- 
tral and western Europe have served free meals to 
their necessitous school children. Denmark supplies 
by public taxation free lunches to one third of the 
pupils in the elementary school; Brussels to one fifth, 
and in one borough to all. One half of the German 

^ Chapter xxi. 



MALNUTRITION IN SCHOOL CHILDREN 117 

cities serve either breakfast or luncheon. Munich 
began the work over a century ago, and now continues 
the free meals right on through the holidays. Fifty 
cities of Italy were serving free meals in 1910, about 
one half of the expense being met by taxation. Vercelli 
has a unique and praiseworthy system, making attend- 
ance upon the free meals compulsory for all the chil- 
dren. Padua has served free school breakfasts since 1901 
to the number of about one half million annually at 
a cost of about two cents each. Tonzig (41), who has 
studied the Padua School dietaries, reports that for 
very many of the children it is imperative that half of 
the day's food requirement be met by the free t)reak- 
fast if the children are not to starve. In Italy break- 
fast is usually preferred to luncheon. Free meals are 
common in nearly all the cities of Norway, Sweden, 
Switzerland, Spain, France, and England. London 
expends over $300,000 annually in this way, but in 
London, as in other English cities, every case must be 
passed on by charity organizations, food being sup- 
plied free only in cases of extreme necessity. The usual 
criterion of necessity is a family income of less than 
three shillings (seventy-five cents) per child per week. 
Real want, of course, begins well above this point. 

The most advanced country in the treatment of 
necessitous school children is France, which supplies 
free meals and clothing in nearly every city. Marseilles 
feeds 10 per cent of her school enrollment. Nice serves 
free luncheons to all of its kindergarten children with- 
out distinction. Nearly all of the recently constructed 



118 THE HYGIENE OF THE SCHOOL CHILD 

school buildings in the towns and cities of France are 
supplied with kitchens as a matter of course. The Paris 
system of feeding is the finest in the world. Lunches are 
served in practically every school and are patronized 
by teachers and pupils, rich and poor. Children who can 
afford to pay for their meals are expected to do so, but 
those who bring no money are given their meal tickets 
without question. The method of supplying tickets is 
such that no child knows which ones of his fellows get 
their meals without payment. One third of the chil- 
dren of Paris receive free lunches by this system, and 
one thirtieth of the total school expenditures are for this 
purpose. In Paris, after a third of a century of experi- 
ment, the tendency is to enlarge the school dietary and 
to exact less and less in the way of payment. 

America is behind Europe, but is making rapid prog- 
ress. Boston first served free meals in 1894, and now 
supplies them in several schools at the low cost of two 
cents. New York, which began in 1909, has a School 
Luncheon Committee, under whose auspices substan- 
tial school meals are served in various centers at the 
low price of three cents, with an opportunity for 
"penny extras." Chicago undertook the work on a 
fairly large scale in 1910, and at the present time 
something is being done in most of our larger cities. 
Although the beginning is most promising, probably, 
the country over, not more than one ill-nourished child 
out of a hundred is receiving the full attention his 
case merits. With us the school lunch is seldom free, 
and ordinarily receives no public support beyond the 



MALNUTRITION IN SCHOOL CHILDREN 119 

kitchen equipment and supervision. The remaining 
expenses are met by the fixed charge for meals and by 
various charity organizations, parents' clubs, private 
philanthropy, etc. 

School meals should, when possible, be under expert 
dietary supervision so that the maximum amount of 
food value may be secured for a given outlay. In small 
schools attended by older children it is often feasible 
to enlist the services of pupils in the preparation and 
serving of the meal, and in clearing the table, washing 
dishes, etc. This is commendable because of its educa- 
tive value. Experience proves that when the cost of 
raw materials alone is met by the children an aj^petiz- 
ing and nutritious meal may be served for about three 
cents. In Philadelphia one cent buys about one hun- 
dred calories. The foods most in evidence are sand- 
wiches, soup, macaroni, shredded wheat, rice pudding, 
cereals, potatoes, hominy, fruits, milk, cocoa, etc. It is 
necessary in some schools to take account of racial food 
preferences. As regards expense, until the time comes 
when the school lunch takes its regular place as a part 
of the school program, as free as tuition, the Paris 
method of meeting the cost is nearest to the ideal. 

Nowhere is reform more urgent than in the lunch 
ceremony of the rural school. Because children live in 
the country is no reason why they should eat with dirty 
hands and piggish manners. As Mrs. Ellen Richards 
suggests, the noon hour in these schools could very well 
be utilized for social training and the acquisition of 
good habits and refined tastes. Mrs. Richards (37) 



120 THE HYGIENE OF THE SCHOOL CHILD v 

s 

sketches an admirable plan for the rural-school lunches, 
including such details as the arrangement of the table 
at which the pupils eat the lunches they have brought 
from home; the use of paper napkins, paraffin paper for 
plates, and a kerosene heater for preparing some spe- 
cial dish to supplement the individual lunches. The 
material for the supplementary dish can be paid for 
by penny or two-cent contributions from the pupils. 
A mothers' organization or a local church can usually 
be found to defray such shortages as may arise from 
the inability of a few pupils to pay their share. By 
varying the supplementary dish and by permitting the 
older children to aid in its preparation much excellent 
instruction in cookery can be worked in. Why not 
a toothbrush drill to follow the meal.? 

In combating malnutrition two other important 
lines of influence are open to the school. Open-air 
schools, with their shorter study program, emphasis 
on play and manual work, the after-lunch sleep period, 
medical supervision, etc., are no less important than 
school feeding. The two methods of treatment should 
go hand in hand. 

Even the mere contact of air currents with the body 
profoundly influences its metabolism. Experiments of 
Rubner (quoted in SI) prove that air currents too mild 
to be perceptible have this effect from passing over a 
small exposed surface like the forearm. The sensation 
threshold for air currents is about one half meter per 
second, while metabolic changes were detected for air 



MALNUTRITION IN SCHOOL CHILDREN 121 

currents of one third this velocity. The effect of a 
thoroughgoing outdoor regimen must therefore be very 
great. 

Another method to be commended is that of under- 
taking systematic instruction of parents on children's 
food requirements. This method has been used by 
Poelschau in Charlottenburg with gratifying results. 
Leaflets were prepared setting forth in simple, untech- 
nical language the importance of food for healthy 
growth, and giving suggestions on such subjects as food 
values, balance of foods, sample dietaries for children 
of different ages, the injury produced by alcohol, tea, 
coffee, abuse of sweets, etc. In the worst case^ it is 
advisable for school nurses to visit the homes and give 
personal assistance and advice. The food leaflet is an 
easy means of reaching all the homes, and while the 
advice it contains will often fall upon stony soil, the 
amount of good accomplished is probably very great in 
comparison to the time and expense involved. It may 
be sent to every home once each school year, and in the 
case of the badly malnourished it may be supplemented 
by additional leaflets giving more detailed suggestions. 

The problem of malnutrition is one which presents 
numerous aspects and varied relations, raising, as it 
does, fundamental questions in sociology, economics, 
physiology, and hygiene. The problem is not solved 
by an occasional dole of food in or out of the school. 
What is demanded is a constantly adequate diet, better 
housing and clothes, opportunity for play, rest, and 
sleep, and vigilant medical supervision of the entire 



122 THE HYGIENE OF THE SCHOOL CHILD 

life. With the possible exception of housing, the school 
can make an immense contribution along all these lines, 
and by appropriate education in household science, 
hygiene, and related matters can give us a new type of 
parent for future generations of children. 

Children's dietaries 

For extended treatment of this subject the reader is 
referred to references; as 6, 14, 20, 21, 23, and 34, at the 
close of this chapter. It is a subject which should be 
taught in one form or another from the sixth grade to 
the university. Only a few points of special importance 
will be touched upon here. 

Children need much more food than adults in pro- 
portion to size. The child of 6 is less than one third of 
the adult weight, but requires one half as much food. 
Almost as much food is required for the child of 12 
as for the adult engaged in moderate labor. If diet 
is insufficient during adolescence, irreparable harm is 
likely to result. Throughout childhood the danger is 
on the side of undereating rather than overeating. 
When children are given the appropriate variety of 
wholesome foods and are required to masticate thor- 
oughly, the matter of quantity can be left for automatic 
adjustment. 

In addition to repairing the daily losses, the child 
must grow, and it is therefore hardly to be supposed 
that the low calories allowance favored by Chittenden 
for adults would be suitable for children when propor- 
tionately reduced. It has not even been proved suffi- 



MALNUTRITION IN SCHOOL CHILDREN 123 

cient for adults, indefinitely and under all conditions. 
The results of superabundant feeding in open-air 
schools, etc., would seem to suggest the importance of 
a factor of safety in children's diet. In order to provoke 
the greatest amount of food assimilation by the tissues 
it is probably necessary to offer them a little more than 
they actually need. A very slight deficiency extended 
over three meals a day for 365 days in the year may, in 
the long run, make all the difference between a well- 
nourished and a poorly nourished child. During conva- 
lescence from illness the problem of diet becomes doubly 
important. 

The science of nutrition involves its psychoWical 
as well as physiological and chemical factors. A theo- 
retically perfect diet may work poorly in practice be- 
cause of the mental attitude it calls forth. Food that 
provokes disgust or any other unpleasant feeling is 
badly digested. Food preferences and aversions some- 
times have a physiological basis, but are sometimes 
the result of prejudice and bad food habits. Bell (4) has 
shown the infinite variety of these, and the important 
part played by them in determining children's diet. 
When the aversion is such that repeated effort on the 
part of the child does not eradicate it, or when nausea 
and vomiting are provoked, it is best to omit the article 
of food altogether. But those who superintend chil- 
dren's meals should take every opportunity to uproot 
such aversions and injurious preferences as are founded 
purely on whim and habit. 

One boy known to the writer persistently refused 



124 THE HYGIENE OF THE SCHOOL CHILD 

for many years milk, butter, meat, turnips, carrots, 
green beans, lettuce, celery, parsnips, beets, cooked 
tomatoes, and cabbage. Contracting tuberculosis at 
the age of 21 years, he was led to consider the desira- 
bility of overcoming his food prejudices. He, therefore, 
set about the matter in earnest, with the result that 
for all but one of the foods (parsnips) the aversion was 
readily overcome, almost at the first trial! 

Bell's investigation of the food preferences and aver- 
sions of over 1400 children, mostly 6 to 14 years of 
age, shows that few children escape such aversions alto- 
gether and that very many contract them in the early 
years. Some of the aversions seem to be characteristic 
of certain well-defined stages of growth. The school 
meal oif ers an excellent opportunity for the education 
of the food habits. 

REFERENCES 

1. Dr. A. Albu: "DerAntheil der Schule an den Storungen der 
Entwl. u. Ernahrung der Kinder." Zt. f. Pad. Psych., 1908, 
pp. 243-53. 

2. George S. Badger: "Malnutrition in School Children." Proc.of 
Cong. Am. Assoc. Sch. Hyg., 1912, pp. 186-89. 

3. C. H. Bean: "Starvation and Mental Development." Psych. 
Clinic, 1909, pp. 78-85. 

4. Sanford Bell: "An Introductory Study of the Psychology of 
Foods." Ped. Sem., 1904. (Especially pp. 75-90.) 

5. A. A. Boughton: "Penny Luncheons." Psych. Clinic, 1911, pp. 
228-31. 

*6. Louise Stevens Bryant: School Feeding. 1913, pp. 345. (The 

best treatment of the subject.) 
*7. W. H. Burnham: "Food and Feeding of School Children." 

In Monroe's Encyclopedia of Education, vol. iii, pp. 627-30. 

8. W. B. Cannon: The Mechanical Factors of Digestion. 1911, 
pp. 227. 

9. Charities and the Commons: Chicago's Hungry School Children. 
October 17, 1908, pp. 93-96. 



MALNUTRITION IN SCHOOL CHILDREN 125 

10. Sir James Chrichton-Bi-owne: Parsimony in Nutrition. 1909, 

pp. 111. 
*11. W. S, Cornell: The Health and Medical Inspection of Schools. 
1912, pp. 479-504 and 599-603. 

12. M. £. Derexia: "Malnutrition and How it May Show Itself in 
School Children." Trans. III. Soc. for Child Study, vol. v, pp. 
107-14. 

13. Dock and Bass: The Hookworm Disease. 1910, pp. 250. 

*14. Clement Dukes: The Essentials of School Diet. London, 1899, 

pp.211. 
15. O. H. Dunbar: "Three-Cent Luncheons for School Children." 

The Outlook, 1911, pp. 34-37. 
*16. Dr. Gastpar: "Die Beurteilung des Ernahrungszustandes der 

Schulkinder." Zt. f. Schulges., 1908, pp. 689-705. 

17. Paul le Gendre : " Le regime alimentaire des enf ants et des adoles- 
cents," etc. Inter. Mag. Sch. Hyg., vol. iv, 1908, pp. 202-16. 

18. Sir John E. Gorst: The Children of the Nation. (Chapter v.) 

19. J. L. Heffron: "The Diet of School Children." Jour, of Fed., 
1900, pp. 285-94. 

20. Christine Herrick: "Food Values for Children." Harper's 
Bazar, vol. 31, pp. 160, 180, 282, 302, 384, 426, 450, 461. 

*21. E. B. Hoag: The Health Index of Children. 1^11. (Chapter ix, 

"Foods for Children.") 
22. E. Holt: Diseases of Infancy and Childhood. 1910, pp. 230-37. 
*23. Caroline Hunt: "The Daily Meals of School Children." Bull. 
U.S. Bureau of Education, 1909, pp. 62. 

24. Woods Hutchinson: "Dangers of Undereating." Cosmopolitan 
Magazine, August, 1909. 

25. J. Johnston: Child Wastage. 1908, pp. 131. (Chapter viii.) 

26. W. H. Jordan: The Principles of Human Nutrition. 1912, pp. 
450. 

*27. Kaup and Rubner: Die Ernahrungsverhdltnisse der Volksschul- 
kinder. Berlin, 1909, pp. 170. 
28. Helen Kinne: "School Lunches." Teachers College Record, 

1905, pp. 90-106. 

*29. John Lambert: "The Feeding of School Children." In Kely- 
nack's Med. Insp. of Schools and Scholars, 1910, pp. 231-48. 

30. C. S. Loch: "The Feeding of School Children." Yale Rev., 

1906, pp. 230-50. 

31. Graham Lusk: The Science of Nutrition. 1909,402 pp. (Espe- 
cially chapters viii, x, and xi.) 

32. 'W.Ijeslie Mackenzie: The Medical Inspection of Schools. 1904. 
(See contents.) 

33. Mary J. Mayer: "The Vital Question of School Lunches." 
Review of Reviews, 1911, pp. 455-59. 

*34. Lucy A. Osborne: "The School Luncheon." Ped. Sem., 1912. 
pp. 204-19. 
35. G. Poelchau : " Die Ernahrung der Schuljugend u. ihre Bekamp- 
fung durch Merkblatter," etc. Zt. f. Schulges., 1912, pp. 553- 
661. 



126 THE HYGIENE OF THE SCHOOL CHILD 

36. George Rainey: "Necessitous School Children in London and 
Paris." School Hygiene, 1912, pp. 196-208. 

37. Ellen H. Richards : Good Lunches jor Rural Schools Without a 
Kitchen. Boston, 1906, pp. 12. 

38. Rowntree: Poverty: A Study of Town Life. 1905, pp. 209 Jf. 

39. Br. M. Schuyten: "The Nutrition Coefficient of Antwerp 
School Children." School Hygiene, 1913, pp. 51-53. 

*40. John Spargo: The Bitter Cry of the Children. 1906, pp. 337. 
t41. Dr. C. Tonzig: "Ueber das Schulerfruhstiick," etc. Zt. f. 

Schulges., 1904, pp. 604-29. 
*42. Dr. Wimmenauer: "Ueber d. Bestimmung des Ernahrungs- 

zustandes bei Schulkindern." Zt.f. Schulges., 1912, pp. 601-21. 
43. Charles E. Woodruff: "Nitrogen Starvation." North American 

Review, 1910, pp. 206-16. 



CHAPTER IX 

TUBERCULOSIS AND THE SCHOOL 

The ravages of tuberculosis 

The annual loss of lives from tuberculosis in the 
United States amounts to about 150,000.^ We have 
constantly one half million people ill with the disease. 
About two million others are kept more or less unhappy 
from living in families where the disease is present. If 
the death rate is not materially reduced within th^next 
few years, five million of the present population of the 
United States will die of the disease. More than two 
million children now attending our public schools will 
fall victims to this plague unless something is done to 
save them. This is several times as many as will die 
from smallpox, diphtheria, and scarlet fever together. 

Unlike most diseases, tuberculosis strikes down the 
majority of its victims in the years before middle age, 
when society has already met the cost of rearing and 
educating them and when their economic productivity 
is at its maximum. On an average, each death from 
tuberculosis cuts off twenty-four years of life, seven- 
teen years of which would be highly productive. The 
average period of total or partial disability from the 
disease is about three years. The annual loss in wages, 

^ Probably not more than this number of soldiers were killed in 
battle in all the four years of our Civil War. 



128 THE HYGIENE OF THE SCHOOL CHILD 

medical attendance, etc., amounts to more than one 
billion dollars. This is interest on a capitalized sum of 
twenty-two billions. The loss is equivalent to an aver- 
age annual tax of fifty dollars for each family in the 
United States. The loss each year is almost twice as 
great as our total annual expenditure for public educa- 
tion and more than twice as great as the annual cost 
of our army and navy. 

Most of this loss is ultimately preventable and prob- 
ably one half of it immediately so. Let the teacher com- 
pute the educational harvest that could be reaped by 
the next generation if only one half the yearly cost of 
tuberculosis could be devoted to increasing the number 
of teachers, to the improvement of salaries, to the es- 
tablishment of vocational high schools, continuation 
schools, playgrounds, health supervision, etc. 

By what means and through what agencies may this 
saving be effected.f^ One thing is clear: tuberculosis 
is at present largely a social and educational problem. 
Barring the possibility of some medical discovery 
which would eradicate the disease, the medical profes- 
sion, unaided, will hardly more than enable us to main- 
tain the slight advantages that have already been 
gained. Relatively few cases, indeed, come under the 
notice of a physician until the most favorable time for 
effecting a cure has passed by. The battle cannot be 
won for the present generation, but by concentrating 
our efforts upon children it may be won for the next. 
All the constructive forces of society should be organ- 
ized to this end. 



TUBERCULOSIS AND THE SCHOOL 129 

Tuberculosis in childhood 

The mortality from tuberculosis among adults, after 
remaining almost stationary for at least a century, has 
decreased about 50 per cent in the last three decades. 
Nearly all of this decrease is due to better knowledge of 
the modes of its dissemination and of the efficacy of 
rest, diet, and fresh air in its treatment. 

But statistics show convincingly that children have 
not shared in the fruits of this partial victory. Tuber- 
culosis kills to-day as many children of school age as it 
did fifty years ago. This is made clear by the following 
table from Kirchner, which shows, for various ages, the 
average annual loss of life in Prussia from tuberculosis 
for each 100,000 living: — 



TABLE 18 



Age in years 


Average for females 


1876-1880 


1899-1903 


0- 1 

i 1- 5 
5-10 
10-15 
15-20 
20-25 
25-30 
30-40 
40-50 
50-60 
60-70 


18.3 

13. 

3.2 

3.6 

8.7 

13.5 

19.2 

22.1 

19. 

16.5 

21.5 


16.5 

12, 
3.8 
3.7 
7.1 

10.8 

12.3 

12. 

10. 

10.2 

11.4 



The mortality from tuberculosis below the age of 20 
years is thus seen to have remained practically sta- 



130 THE HYGIENE OF THE SCHOOL CHILD 

tionary from 1876 to 1903, while for other ages the same 
period shows a remarkable decrease. 

Phillips (6, p. 192) presents the same finding for 
Scotland and concludes that the school plays an as- 
tounding part in increasing the liability to tuberculosis. 
His figures comparing the mortality from tuberculosis 
in 1905 with that in 1891 show a slight increase during 
this period for the ages 1 to 4, a decided increase from 
5 to 9 years (8.75 per cent), and a very great increase 
from 9 to 14 (17.39 per cent). 

The extent of the mortality among children of 
school age from tuberculosis, as compared with that 
from so-called "children's diseases," is far greater than 
is usually believed. This is shown for ages 1 to 15 (for 
Prussia) in the following valuable table from Kirchner. 
The table shows what percentage of the deaths occur- 
ring at any particular age are due to each of the diseases 
listed. 

TABLE 19 









Years 






Cause of death 












0-1 


1-2 


2-3 


3-5 


5-10 


10-15 


Whooping-cough 


3.8% 


7.7% 


5.85% 


3.84% 


1.46% 


.18% 


Measles 


1.45 


8.32 


7.63 


5.49 


2.87 


.53 


Diphtheria 


.62 


4.44 


9.50- 


14.51 


12.92 


4.29 


Scarlet fever. . . . 


.32 


2.41 


7.98 


11.67 


13.37 


6.34 


Tuberculosis.. . . 


1.33 


4.32 


6.18 


8.73 


12.40 


30.03 



This table is for girls. The figures for boys are about 
the same except that the percentage from 5 to 10 years 
is 10.11 as compared with 12.4 for girls; and from 10 to 



TUBERCULOSIS AND THE SCHOOL 131 

15 years, 18.41 as compared with 30.03 for girls. An 
examination of the table shows that for the ages 5 to 
10, tuberculosis kills about as many children as scarlet 
fever or diphtheria, and more than three times as many 
as measles and whooping-cough combined, while for 
the ages 10 to 15 tuberculosis kills nearly twice as many 
boys and three times as many girls as the other four 
diseases combined. 

Whooping-cough produces its highest ratio of deaths 
from 1 to 2 years and takes a relatively unimportant 
place before the school age is reached. The mortality 
from measles is highest from 1 to 3 years, low from 5 to 
10, and almost negligible from 10 to 15. Diphtheria 
and scarlet fever show a high mortality rate from 2 to 
10, when a rapid decrease begins. Even during the 
years of school life, a period usually thought to be little 
productive of this disease, tuberculosis is a more fre- 
quent cause of death than any of the so-called "chil- 
dren's diseases." 

But the mortality tables do not inform us as to the 
real prevalence of tuberculosis among children. It is 
now well established that a majority of children con- 
tract tuberculosis before the end of the elementary- 
school period. This was first revealed by autopsies on 
the bodies of deceased children.^ In 1800 such autop- 
sies Ganghofner (6, p. 325) found the following per- 
centages of latent tuberculosis : — 

* For this purpose, of course, only the bodies of children who have 
died of other causes than tuberculosis are used. 



132 THE HYGIENE OF THE SCHOOL CHILD 





TABLE 20 




460 cases 


0-1 year 


7.1 per cent 


536 


1-2 years 


16. 


476 


2-4 


24.5 


271 


4-6 


26.9 


123 


6-8 


26.8 



Heubner, Cornet, Harbitz, Comby, and Still present 
similar figures, while some investigations have given 
even a higher percentage. 

If further evidence of the wide prevalence of tuber- 
culosis among children is desired, it can be gleaned in 
convincing abundance from the results of tuberculin 
tests made upon apparently normal children.^ Von 
Pirquet applied this test to 693 apparently healthy 
children and found a positive reaction, increasing from 
2 per cent in the first year to 35 per cent in the years 7 
to 10. Hamburger (quoted in 7) shows that Von Pir- 
quet's figures are much too low. The latter secured a 
positive reaction in about 9 per cent at 2 years, 50 per 
cent at 6 years, and 95 percent at 12 years. Hamburger 
concludes that tuberculosis is a true children's disease. 
"Just as everybody goes through measles, a disease 
which is acquired during childhood, so we can say that 
almost every one acquires tuberculosis sometime, and 
mostly during the years of childhood." By the same 

1 The most reliable of the tuberculin tests is the one devised by 
Von Pirquet, which is made by scratching the skin and inoculating 
the abrasion with a small amount of tuberculin solution. If tuber- 
culosis is present an inflammatory reaction occurs at the point of 
inoculation within twenty-four hours. While this tuberculin test of 
Von Pirquet is not thought to be absolutely infallible, it is believed 
to be reliable enough to give approximately correct results when 
used with large numbers of individuals. 



TUBERCULOSIS AND THE SCHOOL 133 

test Jacob (quoted in 8) found a positive reaction among 
43.9 per cent of 1927 German school children examined; 
Ito, of Japan, a positive reaction from 43.9 per cent of 
246 boys and from 50.5 per cent of 196 girls; Herford 
(quoted in 7) a positive reaction from 55 to 78 per cent 
of 2594 English children. The incidence has been found 
to be about as great in the country as in the city, and 
to be very high among the children of the best classes. 

The proportion of school children diagnosed as 
tuberculous is, when the tuberculin test is not em- 
ployed, usually very much less, commonly falling be- 
tween 1 and 5 per cent. Thus Dr. Squire's examination 
of 1670 non-selected school children of London j^eports 
.47 per cent as definitely tuberculous (pulmonary tu- 
berculosis), .8 per cent as doubtful, and 2.8 per cent as 
having morbid chest conditions of non-tubercular char- 
acter. Fraenkel, 1906, reports 1.26 per cent tubercu- 
lous among 17,236 school children examined in Berlin 
(1) and from 8.4 per cent (boys) to 10.5 per cent (girls) 
as predisposed to the disease. A more recent investi- 
gation reports 1.61 per cent of the school children of 
Stockholm as infected with open tuberculosis. 

In the United States, school medical examinations 
have usually been too superficial to disclose any ex- 
cept the most marked cases, and to quote statistics 
from such examinations would be misleading. Euro- 
pean examinations are much more thorough. Indeed, 
Grancher (3), of Paris, claims to have demonstrated 
by improved methods of chest diagnosis, without the 
use of tuberculin tests, the presence of the disease in 



134 THE HYGIENE OF THE SCHOOL CHILD 

from 14 to 17 per cent of non-selected school children. 
All the school children in an average district of Paris 
were carefully examined by him and his assistants. Of 
438 boys, 126 were held for reexamination as suspects, 
and of the latter, 62 (or 14 per cent of all) were finally 
diagnosed as positively tuberculous. A similar proce- 
dure with 458 girls gave 131 suspects and 79 (17 per 
cent) as positively tuberculous. A third examination 
of these children confirmed every diagnosis. 

These figures seem high, but when we remember that 
about 12 per cent of our school children later actually 
succumb to the disease, and that very many others 
contract it in a severe form and ultimately recover, it 
does not seem an exaggeration to say that at least 15 or 
20 per cent should be thought of as definitely predis- 
posed to the disease. Kelynack places the number at 
25 per cent. 

What is the essential significance of the above sta- 
tistics .^^ It would perhaps be rash to infer that all who 
contract the disease are in very serious danger of dying 
from it. The fact that by far the larger number recover 
promptly and without suspicious symptoms shows 
that the human body has already acquired a high de- 
gree of resistance. A large minority, however, retain 
the infection in latent form, and often, after the lapse of 
many years, succumb to it. It is now believed by the 
best authorities that many, if not most, tubercular in- 
fections date back to the early years of childhood. The 
pulmonary infection which first becomes evident in 
adult life is probably not usually a primary infection, 



TUBERCULOSIS AND THE SCHOOL 135 

but a continuation of infantile tuberculosis. Experi- 
ments with animals indicate that once infected an ani- 
mal cannot be reinfected, even though the primary 
infection remains and later causes death. Hence, since 
nearly all children have been proved to be harboring 
infection before the years of adult life, those who first 
show the symptoms of the disease as adults are in 
all probability victims of the outbreak of an old and 
latent infantile infection. 

Dr. Pollak (quoted in 4) seems to have proved by the 
study of case histories that an older child with ''mani- 
fest " symptoms has in every case lived in close personal 
contact with a tuberculous person in infancy, most 
frequently in the first three years of life. It is also 
shown that the earlier in infancy the primary infection 
was contracted, the less favorable are the chances of 
recovery. 

The disease once contracted by the child, there are 
four possibilities: (1) spontaneous recovery without 
manifest symptoms of any kind; (2) it may become 
manifest and lead quickly to death; (3) after becom- 
ing manifest the disease may disappear after more or 
less evident illness ; or (4) there may be a relapse after 
apparent recovery. Which of these events will follow 
is determined both by the native vitality of the indi- 
vidual and by the circumstances of his environment 
and mode of life. 

The seat of infection in children of school age is less 
often in the lungs than in the lymphatic glands or 
bones. The swollen cervical glands, so often considered 



136 THE HYGIENE OF THE SCHOOL CHILD 

a symptom of little importance, are frequently, if not 
usually, tuberculous. Adenoids and enlarged tonsils 
are also often infected. Of 905 adenoids examined by 
Dr. Peters (6, p. 55), 45 per cent were found infected. 
Uicoll found 10 per cent. 

It is estimated that tuberculosis of the bone has 
made cripples of at least 150,000 people in the United 
States. This form of the disease attacks most fre- 
quently the spine, hip, or knee. Of 1000 cases analyzed 
by Young (6, p. 174), 416 involved the spine, 421 the 
hip, and 103 the knee. It is tuberculosis of the spine 
that produces the deformity known as hunchback, 
while active infection of the hips and knee are familiar 
to all as "hip-disease" and "white-swelling." The 
most frequent onset of bone tuberculosis is between 2 
and 9 years; of the spinal cases, 72 per cent begin be- 
tween 1 and 5 years; and of the hip cases, 64 per cent 
between 2 and 6. About 20 per cent of the bone cases 
die either during the progress of the disease or within 
a few years. The "expectation of life" is considerably 
below normal for spinal tuberculous cripples (6, p. 
189). 

With tuberculosis of the bone, as with the pulmon- 
ary form of the disease, the greatest stress should be 
placed upon early diagnosis. When treatment is begun 
early enough, recovery is almost sure, and in a major- 
ity of cases without resulting deformity. But it is stated 
on good authority (6, p. 189) that in 95 cases out of 100 
of spinal tuberculosis deformity has set in before the 
diagnosis has been made. The child with frequent or 



TUBERCULOSIS AND THE SCHOOL 137 

occasional pains, slight rigidity, or tenderness in the 
joints should be an object of suspicion. 

As regards the sources of contagion, authorities con- 
sider the home the most important. Kirchner, Gran- 
cher, and Walsh have followed up a number of severe 
school cases, and have almost invariably found tuber- 
culosis or squalor, or both, in the home environment. 
Milk may be an occasional source of infection in early 
infancy, but is now thought to be responsible for rela- 
tively few cases among older children. Only a few can 
be directly of school origin for the reason that tubercu- 
lous school children seldom have the disease in the 
open form and are thus not sources of danger J:o their 
fellows. Practically the only school danger comes 
from the teacher herself. From 1 to 3 per cent of 
teachers have been found tuberculous. There are prob- 
ably a quarter of a million school children daily exposed 
to infection from this source in the United States.^ 

Means of prevention 

No plan of campaign against tuberculosis can pos- 
sibly meet success which does not center its main efforts 
upon infancy and childhood. Since, according to Ham- 
burger, the pulmonary tuberculosis of adults is only the 
tertiary form of a primary infection which occurred in 
infancy, and of which the gland and bone infections of 
school children are the secondary form, the logical and 
most effective method would be to prevent the infec- 
tion of infants by removing them from all contact with 

1 See Lewis M. Terman: The Teachers Health. 1913, pp. 138. 



138 THE HYGIENE OF THE SCHOOL CHILD 

persons who are tuberculous. But this would involve 
the breaking-up of family life to an extent which pres- 
ent laws do not permit or public opinion sanction. 
Something can be done by providing free public hos- 
pitals and camps in which the tuberculous patients 
among the poorly housed could be isolated. Housing 
laws, of course, accomplish something by lessening the 
chances of infection. What many a child most needs to 
keep him well is room to live, sunlight, air, and the op- 
portunity to play. Poverty that condemns children to a 
life of squalor and to insufficiency of nutrition harbors 
and protects the disease against the most determined 
assaults of the hygienist crusader; and there is yet no 
formula for the abolition of poverty. The protection of 
children from tuberculosis is a problem whose solution 
can be attained only by the wholesale cooperation of 
medicine, politics, statesmanship, industrial reform, 
, and education. The most effective of these is education. 
Infection with tuberculosis in early childhood is so 
common even among the more fortunately situated 
classes that probably for many years to come a con- 
siderable proportion of children will have contracted 
the disease before the beginning of school life. We can- 
not place our main reliance, for the present, upon the 
prevention of the primary infection. Instead we should 
go on the assumption that when the child enters school 
he has probably suffered a primary infection. We 
should then proceed so to order his life, by means of 
the school, that the secondary form of the disease will 
be forestalled. If we fail in this, we should concentrate 



TUBERCULOSIS AND THE SCHOOL 139 

our eflForts to bulwark the body against the tertiary, or 
"open," form of the disease. It is foolish to begin our 
expensive operations with the third and last act of the 
drama. 

What the school can accomplish 

The school offers the only satisfactory opportunity 
for an early diagnosis of the tubercular predisposition. 
The utilization of this opportunity to the fullest would 
gives us an enormous strategic advantage. Unfortu- 
nately it has not been utilized. Our school medical 
examinations are entirely too superficial to uncover 
anything less, obvious than the open case or the most 
extreme predisposition. The work of Grancher^and his 
pupils shows how inadequate and misleading is the 
average school medical report which returns no more 
than 1 per cent of the pupils as showing symptoms of 
tuberculosis. 

When the tuberculous or pre-tuberculous child has 
been found, the leading aim of the school thereafter 
should be to fortify his body against the disease. 
Everything else should give way to this. Teaching and 
instruction should thereafter be considered entirely 
incidental to this one central aim. This should include 
provision for appropriate nourishment (to be supplied 
by the school if it is not forthcoming at home), open- 
air schools, rest and sleep, abundance of outdoor play, 
a specially adapted program of instruction, and con- 
stant medical oversight. The home should be visited 
and parental cooperation enlisted in every possible way. 
The school physician should make frequent reexamin- 



140 THE HYGIENE OF THE SCHOOL CHILD 

ations, including blood tests, and should keep in the 
closest touch with the teacher and school nurse. When 
vacation comes it is folly to dump the child back into 
his hovel or cramped tenement "home." Instead he 
should be taken to the country or be given the privilege 
of the "vacation colony." 

Assuming that the tuberculous child has been 
brought safely through to the end of school life, one 
more obligation remains; namely, a final and thorough 
physical examination followed by some earnest voca- 
tional advice which will insure the choice of a trade or a 
profession least dangerous to the person of tubercular 
tendency. The child should be given a card on which 
the most important occupations are listed in the order 
of danger from tuberculosis. The cause of hygiene and 
the economic welfare of the country could both be 
served by persuading children of tubercular tendency 
to take up farm life in preference to shop or office work 
in the city. Vocational guidance will find its most 
scientific basis on the side of physical diagnosis and 
medical advice. 

In countless other ways the school can safeguard the 
children so as to forestall the secondary and tertiary 
stages of the disease. To accomplish this most effec- 
tively the following measures are necessary : — 

(1) Adequate instruction of children in the main 
principles of personal hygiene. Instead of being re- 
served for incidental treatment, hygiene should be con- 
sidered as one of the three or four most important sub- 
jects of the course of study from the kindergarten to 



TUBERCULOSIS AND THE SCHOOL 141 

the university. A large share of hygiene instruction 
could well be devoted to the causes and prevention of 
tuberculosis, since the instruction most effective for 
this purpose will be either directly or indirectly applic- 
able to the prevention of other diseases. 

As Gulick has emphasized, the special instruction on 
a topic like tuberculosis should not be crowded into 
one or two years of school life. Information thus hur- 
riedly acquired is not assimilated in any vital way. 
The subject should be taken up year after year from 
different angles and by methods adapted to the child's 
stage of development. In the earlier years the instruc- 
tion should take the form of the inculcation of ihabits 
and ideals of cleanliness which are inimical to the dis- 
ease. At this stage it is not necessary, or even desirable, 
to impart specific information regarding the nature of 
tuberculosis, nor need it even be mentioned by name. 
By the third or fourth grade, more specific instruction 
should begin and should be planned so that each year 
some new aspect of the subject is made thoroughly 
familiar to the pupils. In one grade the stress could be 
placed upon the value of fresh air and the ordinary 
means of obtaining a maximum amount of outdoor life. 
In another grade the relation of tuberculosis to alcohol 
could be made prominent. At another time, the influ- 
ence of fatigue, ill-nourishment, etc., and still later the 
social and economic aspects of the problem. Not all 
the necessary knowledge of the related physiology and 
anatomy can be assimilated in any one grade, and 
accordingly this should be worked in piecemeal as the 



142 THE HYGIENE OF THE SCHOOL CHILD 

child's ability to understand it develops. Thus, year 
after year, while taking care to avoid the inculcation 
of an unreasoning fear, the instruction can be driven 
home and the child made to appreciate the necessity of 
so ordering his life as to insure a reasonable security 
from the disease. 

(2) In order to pave the way for the improved 
methods of teaching hygiene in the public schools, 
another reform is first necessary. The teachers them- 
selves will have to receive more adequate instruction. 
Here the cooperation of the normal school is neces- 
sary. Reform should logically begin at the top. Mean- 
while, something can be done by superintendents and 
school physicians to educate the rank and file of teach- 
ers-in-service along this and other lines of personal and 
social hygiene. 

(3) The course of study and program of instruction 
also need to be reformed to accord better with the 
psychological laws pertaining to economic methods of 
learning, fatigue, the hygienic use of the school day, 
etc. If by improved methods one or two hours per day 
can be saved from instruction in writing, spelling, 
arithmetic, etc., without loss to the child in those sub- 
jects, hygiene demands that part or all of the time thus 
gained be devoted to other activities more conducive 
to health than the usual sedentary occupations of the 
school. The latter could be limited to two hours in the 
lower grades, to three hours in the middle grades, and 
to four hours in the eighth grade, without loss. Play, 
rest, manual work, gardening, and elementary agricul- 



TUBERCULOSIS AND THE SCHOOL 143 

ture could fill up the remainder of the school day, to 
the child's great profit both physically and mentally. 
Overwork of the predisposed child, in school or out, is 
a potent influence transforming a latent into a mani- 
fest infection. When animals which have been ex- 
perimentally inoculated with the disease are compelled 
to overwork in a treadmill, they succumb much more 
quickly than those which are not so treated. 

(4) The widespread interest in playgrounds should 
be still further encouraged. The nation has not yet 
one tenth enough. In the city the employment of play- 
ground instructors should be as much a matter of course 
as the employment of the classroom teacher. Nbrmal 
schools and teachers' colleges have here one of their 
most important functions. Every outgoing teacher 
should have had some instruction in the psychology 
and hygiene of play, and some practical experience in 
the supervision of children's games. The special play 
teachers, of course, need a thorough grounding in all 
aspects of the subject. There can be no ideal school 
without its spacious playground and its agricultural 
plot. 

(5) Baths should be installed in public schools and 
their use encouraged. These will come to be looked 
upon as more necessary in proportion as play and other 
out-door activities are introduced into the school day. 
School baths do more to instill habits of personal clean- 
liness than any amount of didactic instruction. The 
shower bath should be regarded as one of the necessi- 
ties in school architecture, just as we now look upon 



144 THE HYGIENE OF THE SCHOOL CHILD 

toilet conveniences, lavatories for the hands and face, 
drinking-fountains, etc. 

(6) Seating and posture must receive attention if 
the lungs are to be normally developed. The experi- 
ments of Badaloni are here in point.^ Idle lung tissue 
must be reduced to a minimum, for that is the kind 
tuberculosis prefers to nest in. 

(7) School buildings, until we can contrive to get 
along without them, should be better ventilated and 
should be kept free from dust. It is useless to expect 
the linings of nose, throat, and lungs to remain healthy 
as long as the air passages are kept in a constant state 
of irritation by the mineral dust of the average 
schoolroom. Schoolrooms can be kept practically free 
from injurious dust.^ 

(8) Since tuberculosis is so intimately related to the 
alcohol problem, the school finds here an additional 
motive for enlisting in the cause of temperance. 

(9) School dental and medical clinics for free treat- 
ment are an indispensable measure in the fight against 
tuberculosis. Only by this means will the host of minor 
ailments, so important in the prevention of tubercu- 
losis, be given the appropriate amount of attention. 
For want of attention to the minor ills many children 
are now lost. The child has as much right to the medi- 
cal treatment which will make his health and education 
possible as he has to the education itself. The amount 
of medical and dental treatment received by children, 

1 See page 397. 

2 See Hoag and Terman: Health Work in the Schools. 1914. 
(Chapter on " School Housekeeping.") 



TUBERCULOSIS AND THE SCHOOL 145 

in proportion to that which is needed, is about as inade- 
quate as their education would be if there were no pub- 
lic schools. The requirements of the body are as much 
a matter of social concern as the needs of the intellect. 
Neither can safely be left to private initiative and to the 
business enterprise of quacks. 

(10) As already stated, probably a quarter-million 
children could be protected from the danger of con- 
tagion at school if the tuberculous teacher were elimi- 
nated. By means of a system of retiring allowances 
this could be done without injustice to any teacher. 

(11) In view of the very much greater incidence of 
tuberculosis among girls than among boys in the^arlier 
years of adolescence, it seems highly desirable that the 
hygienic regimen of the adolescent girl be improved. 
This would doubtless necessitate reforms both in the 
school and in the home. Special attention should be 
given to the health instruction of girls, not only for their 
own good, but also because as teachers, mothers, and 
keepers of the home, they will always and inevitably 
play a leading part in the hygiene of the succeeding 
generation. 

(12) The prevalence of malnutrition has been treated 
in chapter viii. It need here only be pointed out that 
our tuberculous patients are recruited largely from the 
15 or 20 per cent who as children presented the symp- 
toms of malnutrition. These children must be reached 
in some way, and it is doubtful whether there is any 
way which does not lead through the school. 

(13) It has been shown that the period of con vales- 



146 THE HYGIENE OF THE SCHOOL CHILD 

cence from an attack of whooping-cough or measles is 
often marked by the passage of a primary infection 
into the secondary stage, or of a secondary infection 
into the tertiary. Hence weakly children need to be 
watched more carefully and permitted a longer period 
of rest than is customary in such cases. Teachers and 
parents should have special instruction on this point. 
It is impossible to forecast every detail of the school's 
contribution to the warfare against tuberculosis. We 
must emphasize, however, that little ground will be 
gained unless all social agencies cooperate in a broad 
way and use every resource at their command to safe- 
guard the child. Private philanthropic measures, good 
as far as they go, can never cope with the problem in 
any effective way. Because the school offers the chief 
means of access to children, it is necessary to make it 
the main battleground in the conflict.^ 

REFERENCES 

*1. Dr. Fraenkel: "Tuberkulose u. Schule." Zt.j. Schulges., 1906, 
pp. 389-409. 

*2. Dr. Granjux: "La tuberculose a I'ecole." International Arch, of 
Sch. Hyg., vol. ii, pp. 334-50. (Summary of contributions pre- 
sented at the 1905 International Congress for the Prevention of 
Tuberculosis.) 

3. Dr. Grancher: "Preservation scolaire contre la tuberculose." 
International Arch, of Sch. Hyg., vol. i, pp. 131-45. 

4. Dr. Franz Hamburger: "Tuberculosis in Childhood." School 
Hygiene, 1912, pp. 119-21. 

5. Dr. Emmett Holt: Diseases of Infancy and Childhood. 1909, 
pp. 1070-1106. 

*6. Dr. T. N. Kelynack (editor): Tuberculosis in Infancy and 
Childhood. 1908, pp. 376. (Written by many authors. Very 
important.) 

1 See Hoag and Tennan's Health Work in the Schools, chapter on 
•* Open-air Schools." 



TUBERCULOSIS AND THE SCHOOL 147 

7. Dr. James Kerr: "The Elementary Schools and Tuberculosis." 

School Hygiene, 1910, pp. 14-20. 
*8. Dr. M. Kirchner: "Tuberkulose u. Schule." Zt. f. Schules, 

1912, pp. 1-27. (Beiheft giving proceedings of the 12th German 

Congress of School Hygiene.) 
*9. Dr. M. Kirchner: Die Tuberkulose in der Schule. Berlin, 1909, 

pp. 16. . , . 

10. F. Lorentz: "Metodische Atemiibungen in der Schule u. ihr. 

Wert f. d. Tuberkuloseverschiitzung." Zt. f. Schulges., 1912, 

pp. 793-800. 
*11. Dr. Arthur Newsholme: The Cause and Prevention of Tubercu- 
losis. London, 1908. 

12. Dr. Arthur Newsholme: "The School in Relation to Tubercu- 
losis." Proc. Second International Cong, of Sch. Hyg., 1907, pp. 
426-30. 

13. Dr. Nietner: "Die Bekampfung der Tuberkulose unter den 
Schulkindern." International Mag. of Sch. Hyg., 1912, pp. 
460-76. 

14. Dr. Mario Ragazzi: "La scuola nella poriBlassi della tuberco- 
losi." International Mag. of Sch. Hyg., vol. iv, pp. 339-73. 

*15. Dr. Wimmenauer: "Ueber Tuberkulinempfindungen nach v. 
Pirquet bei Schulkindern." Zt. f. Schulges., 1912, pp% 245-62. 

16. See International Mag. of Sch. Hyg., 1912, pp. 309-30 for sum- 
mary of proceedings of the 1912 International Congress for the 
Prevention of Tuberculosis (especially papers of Badaloni, 
Jacob, D'Espine, Mery, and Wileminsky). 

17. See Proceedings of Sixth International Congress for the Preven- 
tion of Tuberculosis (especially vol. vi). 



CHAPTER X 

THE PHYSIOLOGY OF VENTILATION 

"Shades of the prison house begin to close upon the growing boy." 

Air is food as truly as meat or bread. We feed the 
stomach at most but three or four times a day, the 
lungs about fifteen times a minute. We are nice and 
discriminating about the food which we offer the stom- 
ach, but we complacently consume lung food which is 
clouded with dangerous mineral dust or filthy with 
organic matter derived from the skin, teeth, and mu- 
cous membranes of other persons. To a sense of smell 
of ordinary delicacy a first whiff of typical schoolroom 
air is likely to be found nauseating and stifling, like 
the morning air of an un ventilated bedroom. 

The immediate effects produced by ill- ventilation 
are headache, drowsiness, lassitude, faintness, dizzi- 
ness, nervousness, and in extreme cases even death. 

After the battle of Austerlitz, of 300 Austrian pris- 
oners who were herded in a small, ill-ventilated prison, 
260 were killed by impure air. Inl848, about 100 steer- 
age passengers of an English ship were locked up in a 
room 18 by 11 feet, without ventilation. When, a few 
hours later, an exit was forced amid scenes of frenzy 
and violence, 72 were found dead. 

The indirect and remote effects of chronic exposure 
to unsuitable air are not so well known because they 



THE PHYSIOLOGY OF VENTILATION 149 

are not so spectacular, but they are none the less real. 
Bad ventilation is a factor in the production of nearly 
all kinds of diseases which have their seat in the respir- 
atory passages, including tuberculosis, pneumonia, 
diphtheria, colds, laryngitis, pharyngitis, nasal or 
bronchial catarrh, hypertrophied tonsils, and adenoids. 
Imperfect aeration of the blood causes general debility. 
This means lowered resistance to fatigue, to disease, 
and probably also to temptation. Neither physical nor 
moral victories go to the anaemic. 

Red blood is at a premium everywhere: in the pul- 
pit, in the judge's chair or the jury's box, in the doc- 
tor's office, at the superintendent's desk, in factory or 
mine or battle. It protects us from tuberculosis, pneu- 
monia, influenza, and many other diseases, or enables 
us to win in the fight against them when they have 
secured a hold. Hardly a disease is known which may 
not be more or less favorably influenced by the open- 
air treatment. 

What is the secret of this.? In order to answer the 
question it will be necessary to consider briefly the 
physiological aspects of the ventilation question. 

Our ventilation problems have been turned over to 
the mechanical engineer, but he has not solved them 
and cannot solve them alone. Ventilation is first of all 
a physiological problem, only secondarily and inci- 
dentally one of mechanical engineering. The real ob- 
ject is not schoolroom ventilation, but body venti- 
lation. This is a physiological problem. 

The ventilation "expert" has assumed that indoor 



150 THE HYGIENE OF THE SCHOOL CHILD 

air is healthful when it is kept at a given uniform tem- 
perature (about 72 degrees), when the carbon-dioxide is 
kept below three parts in ten thousand, and when the 
exchange of air is effected without perceptible drafts. 
There are ventilating systems on the market which ful- 
fill these demands and which are often spoken of as 
ideal. But there is no scientific evidence that a school- 
room ventilated in this way is more healthful than one 
which has to depend entirely upon window ventilation. 
On the contrary, the experimental evidence seems to 
prove that no system of mechanical ventilation has 
succeeded in making indoor air healthful. Recent 
physiological researches on this point even suggest 
the conclusion that the "ideal" ventilation above de- 
scribed is, in its ultimate effects upon the human body, 
anything but ideal. 

The ^physiology of respiration 

In order to locate the engineer's fallacy it is neces- 
sary to review some elementary facts pertaining to 
the physiology of respiration. 

(1) All life processes involve an interchange of gases. 
In one-celled animals this interchange occurs directly 
through the cell walls. This is not possible for all the 
cells of the human body, because most of them are too 
far removed from the source of supplies. Oxygen must 
be carried to them and gaseous wastes must be sewered 
away. Therefore we are furnished with lungs and 
the blood, which work together for the aeration of 
the farthermost living cell, the one by furnishing the 



THE PHYSIOLOGY OF VENTILATION 151 

means of intake and outlet, the other by serving as the 
agent of distribution and elimination. 

The lungs, with their millions of air cells (variously 
estimated at from 4,000,000 to 700,000,000), afford, 
when extended by inspiration, not far from 1350 square 
feet of surface available for the absorption and elimi- 
nation of gases. The oxygen is combined with the red 
corpuscles of the blood and carried to every part of the 
body. In similar manner the blood transports carbon- 
dioxide and other wastes from every living cell to the 
lungs and there rids the body of them. 

(2) This interchange of gases is by no means a local 
problem for the lungs alone. The lungs may |je fully 
developed and healthy, but if the blood be deficient in 
haemoglobin (the oxygen-carrying element of the red 
corpuscles), the cells of the body gradually suffocate, 
just as the inhabitants of a city would famish if the 
distributing mains from the only available water-sup- 
ply were to become permanently clogged. An army's 
commissary may be ever so well filled, but if its com- 
munication with the army is blocked, the army cannot 
live and fight. 

(3) Good lungs and pure air are further supple- 
mented by the action of the heart. We breathe as 
much with the heart as with the lungs. With a strong 
heart and plenty of healthy oxygen-carriers in the 
blood, a person need not be concerned about the size 
of his lungs. Other conditions being favorable, the 
lungs are nearly always large enough to accomplish 
their work; and however large they may be, their effi- 



152 THE HYGIENE OF THE SCHOOL CHILD 

ciency is strictly dependent upon the freight capacity 
of the circulatory system. Large lung capacity does 
not give increased resistance to tuberculosis. The dan- 
ger lies, not in lungs which are naturally small, but 
in unused lung tissue. 

(4) But heart, blood, and lungs together cannot 
force oxygen upon tissues that are n'ot oxygen-hungry. 
Proverbially you can lead the horse to the trough, but 
you cannot make him drink. In increasing the hunger 
of the tissues for oxygen, nothing else is as effective 
as muscular activity. The active sparrow throws off 
ten times as much carbon-dioxide in proportion to 
body weight as the sluggish toad, the boy of 10 years 
40 per cent more than the girl of the same age, the 
youth of 19 years 20 per cent more than the old man of 
60. We produce 50 per cent more carbon-dioxide while 
walking slowly than while at rest, and nearly fifteen 
times as much while laboring in a treadmill as when 
asleep. Changing the rate of ordinary walking from 
two miles to three per hour increases the production of 
carbon-dioxide nearly 50 per cent. In the person of 
sluggish habits metabolism languishes. One who never 
exercises actively is literally only half alive. A per- 
fectly ventilated schoolroom is of little avail for chil- 
dren who are held to sedentary book work for six or 
seven hours a day. 

(5) Breathing itself is active, not passive. The air 
does not rush into the lungs and expand them, but the 
muscles concerned in breathing must exert themselves 
at each inspiration to enlarge the thoracic cavity. If 



THE PHYSIOLOGY OF VENTILATION 153 

these muscles are not amply nourished and kept in trim 
by occasional exercise of more than average severity, 
they grow weak and lose in scope of movement. This 
means superficial breathing, a disproportionate amount 
of idle lung tissue, blood insufficiently aerated, and 
general weakness. Again we see that body ventilation 
is impossible in a life of inactivity. 

(6) The air in the innermost lung cells, where the 
interchange of oxygen and carbon-dioxide takes place, 
is never purified directly. The lungs are not emptied 
and filled at each expiration and inspiration. If the 
lung capacity is 3500 cc, the "tidal air," or that which 
is expelled at each expiration, amounts to aboul^500 cc. 
(one seventh). Of the remainder, about one half, or 
1500 cc, can be expelled with special effort. This is 
"reserve air." The other 1500 cc, the "residual air," 
remains absolutely stationary against the alveolar 
membranes. From it the blood gets its new supply of 
oxygen and into it discharges its excess of carbon- 
dioxide. The residual air is therefore always extremely 
impure. Compared with tidal air, it is always deficient 
in oxygen and foul with waste products. The residual 
air cannot possibly be purified by a few deep breaths 
of fresh air. Still less can we aerate the whole body in 
this way. Ten minutes spent in breathing exercises 
before an open window may do the muscles of the tho- 
rax a little good and act as a wholesome moral tonic, 
but this is not a substitute for a day of normal activity 
in the open air. As well might the long-distance runner 
substitute finger exercises for his training. Vigorous 



154 THE HYGIENE OF THE SCHOOL CHILD 

bodily activity impels the rapid production of red cor- 
puscles and the formation of haemoglobin. We breathe 
with the whole body (especially with the muscles), 
not simply with the upper one seventh of the lungs. 

(7) Except in extreme cases, the healthfulness of 
indoor air is not influenced by the changes which occur 
in its chemical composition. The worst ventilated 
schoolroom is never deficient enough in oxygen for this, 
in itself, to constitute the slightest menace to health. 
Always more oxygen is available than is necessary. 
Nor is carbon-dioxide the criminal it was once believed 
to be. There is never enough of it, even in an under- 
ground bakery, to produce any discoverable effects. 
The normal amount in the atmosphere is .03 per cent, 
and the proportion never goes beyond .4 per cent in the 
worst ventilated schoolroom. But experiments prove 
conclusively that it requires about ten times the latter 
amount to produce any noticeable effect, so long as the 
air is normal in other respects. 

As already indicated, the air which we really breathe 
is not the air in the room, but the "residual air" which 
lies next to the alveolar membranes of the lungs. But 
the residual air always contains 5 to 6 per cent of car- 
bon-dioxide, regardless of the degree of purity of the air 
which is inhaled. It is evident, therefore, that carbon- 
dioxide cannot be guilty of the crimes which have been 
charged against it. 

(8) The more recent theory, that the injurious 
effects of bad ventilation were due to the presence of 
organic poisons in expired air, has, in all probability. 



THE PHYSIOLOGY OF VENTILATION 155 

no more foundation than the carbon-dioxide theory. 
The experimental results of Brown-Sequard and 
d'Arsonval, which were thought to prove the toxicity 
of expired air, are now known to have been due to 
imperfect experimental procedure. While the air of 
occupied rooms may contain organic poisons in minute 
quantities, the numerous experimental studies which 
have been directed upon the problem do not justify 
us in believing that under any ordinary conditions 
these are great enough in amount to produce any 
injury. 

Another theory was that the evil effects experienced 
from breathing the air of crowded rooms resul^ from 
the reflex influences produced by odors, which were 
thought to induce changes in respiration, circulation, 
heat production, and nutrition. This theory, also, is 
rejected by the best authorities. 

Every one knows, however, that confinement in ill- 
ventilated rooms is unheal thful. What is the source of 
the injury.? 

Air currents, temperature, and humidity 

These are now believed to be the important factors 
in ventilation; not air poisons or excess of carbon- 
dioxide. They produce their effects chiefly through 
their influence on the heat-regulating mechanism. It is 
impossible to understand the principles of good venti- 
lation without consideration of the body's thermal 
phenomena. 

Whatever the temperature of the air around us, our 



156 THE HYGIENE OF THE SCHOOL CHILD 

bodies must maintain a temperature which is approxi- 
mately uniform. Heat loss and heat gain must exactly 
balance. 

The heat of the body is produced in the same way as 
the heat of the furnace or stove, i.e., by oxidation. Our 
food is our heat fuel. When the body is too rapidly 
cooled, heat production is hastened by increased oxida- 
tion. This acceleration is most readily brought about 
by an increase of muscular activity. In cold weather 
our muscles "tone up" in a condition of partial con- 
traction, and at the same time the circulation be- 
comes more vigorous. In hot weather, when the danger 
is on the side of too great heat production, our muscles 
relax and we become languid. 

But the body's thermal balance could not be kept 
up merely by alterations in the rapidity of heat pro- 
duction. Means are provided also for correspond- 
ing changes in the rapidity of heat loss. 

The body loses heat in three separate but mutually 
supplementary ways; by radiation, by conduction, and 
by the evaporation of sweat. The amount lost by radi- 
ation depends upon the temperature of the surround- 
ing air, upon the clothing worn, and upon the amount 
of blood in the vessels near the surface. The amount 
lost by conduction depends upon all these factors and 
in addition upon the humidity and movements of the 
surrounding air. The amount lost by evaporation de- 
pends upon a number of factors, relative humidity and 
air currents being among the most important. 

To recapitulate, the heat of the body is kept uniform 



THE PHYSIOLOGY OF VENTILATION 157 

by a marvelously delicate system of balances involving 
the following mechanisms : (1) Means for increasing or 
decreasing the rate of heat production, and (2) means 
for regulating the rate of heat loss. The latter is 
accomplished chiefly in two ways; (a) by regulation of 
the amount of blood carried to the skin, and (b) by 
regulation of the activity of the sweat glands. 

Which of the above means will be brought most 
effectively into play in any given case will depend 
entirely on the special conditions. If the air is cold and 
damp, the body tends to lose heat too rapidly by 
radiation and conduction. Accordingly, the blood is 
driven inward by vasomotor constriction of th^ blood 
vessels of the skin, and both conduction and radiation 
decrease. The sweat glands also cease their activity 
so as to prevent still further loss of heat by evapora- 
tion. At the same time the muscles tend to partial 
contraction so as to increase heat production. 

On the other hand, when heat is accumulating too 
rapidly, whether because of vigorous activity or exces- 
sively high atmospheric temperature, vasomotor con- 
trol fills the skin with blood so as to increase radiation 
and conduction, and the sweat glands simultaneously 
hasten their work. If the air is as warm as the body, 
no heat can be disposed of by radiation or conduction, 
and perspiration becomes our sole defense against 
overheating. If the air is excessively humid or still, 
even this defense is destroyed and heat apoplexy may 
result. 

Any condition which interferes with the working of 



158 THE HYGIENE OF THE SCHOOL CHILD 

this complex thermal mechanism is likely to produce 
injury. The disturbances which actually occur are of 
two kinds : external and internal. The external include 
chiefly such factors as unsuitable temperature or 
humidity, and the absence of air currents. The inter- 
nal disturbances include unsuitable activity of the 
sweat glands, of the heat-producing mechanism, and 
derangement of the vasomotor reflexes which regulate 
the supply of blood sent to the skin. 

Of the external influences, temperature and humid- 
ity are the most important. Their physiological effects 
are best demonstrated by means of air-tight cabinets 
such as those used by Paul, Brown-Sequard, and Hill. 
One or more persons are inclosed in the cabinet, and 
the effects of various conditions of humidity, tempera- 
ture, and air movement upon the inmates are noted. 

Dr. Paul found that when the temperature of the 
cabinet was kept at sixty degrees, the experimenter 
could stay in the cage four and a half hours without 
noticeable symptoms, although long before the close of 
the experiment the carbon-dioxide content of the air in 
the cabinet was far higher, and the oxygen content far 
lower, than is ever the case with the worst ventilated 
schoolroom. But at seventy-two degrees, only a few 
minutes were required to produce feelings of mental 
dullness, headache, vertigo, and faintness. Before long 
the body temperature rose three degrees. Then an 
electric fan was started and the symptoms almost 
immediately vanished. 

Hill's experiments with air-tight cabinets proved that 



THE PHYSIOLOGY OF VENTILATION 159 

when the air was kept cool and in motion the subjects 
suffered no ill effects even when the proportion of 
carbon-dioxide was twenty times as great as it ever 
is in badly ventilated houses. At this point, the oxy- 
gen content was so low that candles would not burn 
and the inmates could not light their cigarettes with 
matches. When the temperature of the air was sud- 
denly increased by means of an electric stove, the 
usual symptoms of rapid heart-beat, increased body 
temperature, and feelings of distress quickly made 
their appearance. Electric fans were then started and 
the passage of swift air currents over the body brought 
almost instant relief. ^ 

Hill also imprisoned guinea pigs for periods as long 
as fourteen weeks in tight cages where the proportion 
of carbon-dioxide was from fifteen to thirty times 
above the normal. The guinea pigs throve beautifully 
in spite of the "bad" air as long as their cages were 
kept cool, dry, and clean. 

In other experiments Hill was able to prove that 
breathing the hot and vitiated air had nothing what- 
ever to do with the symptoms. Persons who stood 
outside were able to breathe the vitiated air of the 
cabinet tubes without experiencing any ill effects. 
Conversely, when those inside were suffering extreme 
symptoms due to the overheated and stagnant air of 
the cabinet, they experienced no relief from breathing 
the pure, outside air through the tubes. Only the fans 
and the lower temperature brought relief. The expla- 
nation is as follows : If the air is not in motion, that 



160 THE HYGIENE OF THE SCHOOL CHILD 

next to the body quickly becomes saturated and re- 
fuses to take up additional moisture. It acts as a 
"steam jacket" enveloping the body and causes lan- 
guor and depression. The perspiration is not evapo- 
rated and, as the Germans say, the body is then not 
able to "unwarm" itself. The pulse is accelerated, 
more blood is sent to the skin and less to the viscera 
and brain. The blood vessels of the skin dilate, the 
blood pressure is lowered, and extra work is thrown 
upon the heart. When the dead air is set in motion 
by a fan, the steam jacket is dissipated, the sweat 
evaporates, the circulation becomes more normal, and 
we are refreshed. 

Air currents and perceptible variations of tempera- 
ture are the essence of good ventilation. The "imper- 
ceptible ventilation" for which the mechanical engi- 
neer so industriously labors is beginning to look like a 
delusion and fraud. The thermostat ^ has well been 
called an "invention of the Devil." It is largely our 
prejudice against air currents and variable tempera- 
ture which makes our indoor life so unhealthful. 

By some hundreds of thousands of years of outdoor 
living, before houses were invented, man's body be- 
came so adapted as to thrive under the stimuli of air 
currents and changing temperature. Our few hundred 
years of life in the stagnant atmosphere of stuffy rooms 
have not yet brought the physiological adjustment 
necessary to make such life healthful. Out of doors, 

^ A mechanical arrangement which works automatically so as to 
maintain a uniform temperature of the room. 



THE PHYSIOLOGY OF VENTILATION 161 

even in a very mild breeze, the body is bathed in 
at least five hundred cubic feet of air per minute. It 
enjoys complete '* perflation." ^ Open-air schools per- 
mit perflation; others do not. Indoor schools which 
have to depend on windows for their ventilation may be 
more healthful, in case the windows are frequently 
thrown open to admit a fresh supply of cool air, than 
those with the most improved system of artificial 
ventilation. 

Normal and complete perflation can injure no one 
whose physical defenses have not been weakened by 
coddling. Continued sedentary life does this. As stated 
by Hill, "Our circulation is contrived for a restless, 
mobile animal" (3). Life indoors both lowers vitality 
and increases the opportunities for contagion. Persons 
who have been weakened by hot-house culture have to 
take special precautions with clothing in making the 
transition to outdoor life. 

Instead of fleeing from drafts, we should seek them. 
As long as we are healthy, it is only the little draft, 
which cools but a small part of the body, that is inju- 
rious. The remedy for draft, therefore, is more draft, 
coupled with the healthy circulation that comes from 
sufficient exercise. Even the sickly pupils of the open- 
air school do not catch cold. 

Immunity from colds depends largely upon the 
healthy action of the automatic vasomotor reflexes of 
the skin. When the body needs to be cooled, the walls 

^ Perflation refers to the rapid movement of air over the entire 
surface of the body. 



162 THE HYGIENE OF THE SCHOOL CHILD 

of the blood vessels in the skin relax and become dis- 
tended with blood so as to permit more rapid loss of 
heat by radiation and conduction. When heat needs to 
be conserved, the blood is driven from the skin to the 
interior by the contraction of the surface blood vessels. 
This process is reflexly controlled by a delicate nerv- 
ous mechanism which causes the walls of the blood 
vessels to contract or relax according to the kind of 
signal received. 

Hardly anything is more to be desired than a healthy 
condition of these vasomotor reflexes. When they are 
normal, drafts do not harm us, and we can expose our- 
selves with impunity to sudden changes of tempera- 
ture. The important fact to be noted is that the vaso- 
motor apparatus can be kept normal only by practice. 
If we close all the windows to prevent drafts and 
install a system of heating which keeps the tempera- 
ture of the air at exactly the same point, the walls of 
our surface blood vessels grow lax from disuse and for- 
get how to act. Then when the draft is encountered, 
or when the room is cooled a little below the customary 
temperature, or when we go out of doors lightly clad, 
the body is too rapidly cooled. This is the way we train 
our children to catch cold. No other results need be 
expected until the windows and doors are thrown open 
and the children are permitted to live and learn under 
normal conditions of air and with less suppression of 
physical activity. 

The heart, the capillaries of the skin, the sweat 
glands, and the mechanism for producing heat by 



THE PHYSIOLOGY OF VENTILATION 163 

increased oxidation must all function together in order 
to keep the body at a constant temperature, and the 
exact participation of each factor varies according to 
the temperature, humidity, and currents of the sur- 
rounding air. The balanced cooperation of all these 
reflex controls cannot be maintained except under 
fairly normal conditions of life. The sedentary life of 
the school disrupts all of them. The mechanical sys- 
tem of ventilation at best can ventilate only the school- 
room, while the real end of school ventilation is the 
aeration of the individual cells of the child's body. 
This end will not be attained until we fill the schools 
with perceptibly moving air of ordinary out(i»or hu- 
midity and of a reasonably low, but not quite uni- 
form, temperature; nor will it be attained until we per- 
mit the child to lead a life of normal activity. 

Another of the serious evils of schoolroom air under 
artificial methods of ventilation and heating is deficient 
humidity. When air of 30° F. at a relative humidity of 
60 or 70 per cent is heated to 72°, the relative humidity 
is greatly lowered and the drying capacity of the air is 
increased enormously. On an average winter day the 
air of the "best ventilated" school may show a rela- 
tive humidity of only 25 or 30 per cent; that is to say, 
it is as drying as the winds of the Sahara. Plants less 
hardy than the desert cactus shrivel and die in such an 
atmosphere. Why should we expect children to thrive 
in it? 

So great is the drying capacity of warm air at this 
degree of humidity that it voraciously licks up every 



164 THE HYGIENE OF THE SCHOOL CHILD 

available particle of moisture, from the furniture, which 
promptly cracks and falls to pieces, and from the skin 
and throats of the children. All the mucous membranes 
exposed to such air become parched and unhealthy. 

As shown elsewhere (p. 200), one important function 
of the nasal passages is to add moisture enough to the 
air in its passage to the lungs to raise it almost to the 
point of saturation. In the desiccated air of the furnace- 
heated or steam-heated school, this task becomes too 
great. Diseased conditions of the nose and throat 
result: catarrh becomes the rule; diphtheria, pneu- 
monia, and tuberculosis are more easily contracted; 
and it is possible that adenoids and hypertrophied ton- 
sils may sometimes be caused in this way. 

When the mucous membranes of the nose and throat 
are healthy, they produce a germicidal secretion which 
rids the incoming air of nearly all its bacteria. When 
changed in texture by air of deficient humidity, the 
membrane is no longer a "bulwark against disease," 
but a "host for the culture of germs." "It turns traitor 
to the body by giving aid and comfort to its enemies." 

Another effect of this kiln-drying to which we sub- 
ject children is to make them irritable and nervous. 
Self-control becomes more difficult. Outbreaks of 
temper are frequent. Concentration is impossible. 

It has been suggested that some of the evil effects of 
indoor air may be due to changes which heated and 
inclosed air undergoes in respect to its electric proper- 
ties and radio-activity. The physiological effects of 
radio-activity, however, are yet too clouded in obscur- 



THE PHYSIOLOGY OF VENTH^ATION 165 

ity to enable us to speak with any assurance on this 
point. 

The experimental evidence seems to justify the 
conclusion that living in stuffy rooms is unhealthful 
mainly because of the excessively high temperature, 
unsuitable humidity, and motionless uniformity of in- 
closed air, combined with the habits of physical inact- 
ivity which usually go with this mode of life. If this 
is correct, we should divert the rich stream of public 
money now going to the purchase of expensive venti- 
lating systems to other and more profitable ends. It 
would be a step in the progress of hygiene if we could 
contrive to get along without school building alto- 
gether. Where this is not possible we can at least make 
our schoolrooms into the open-air type by the use of 
large, hinged windows. The air of the ordinary indoor 
school can also be made much more hygienic by fre- 
quent flushing through opened windows. The latter 
precaution, in fact, is a necessary adjunct to any sys- 
tem of ventilation.^ 

REFERENCES 

*1. Karl Brabbee: "Heitzung u. Liiftung von Schulen." Zt f. 
Schulges., Beiheft to no. 8, 1912, pp. 59-75. 

*2. Luther H. Gulick: Report of Committee on Heating and Ven- 
tilation. Proc. Sixth Cong. Am. Sch. Hyg. Assoc, 1912, pp. 
195—202 

*3. Leonard Hill: "Stuffy Rooms." Pop. Set. Mo., 1912, pp. 374-96. 
4. Hough and Sedgwick: The Human Mechanism, 1906, pp. 564. 
(See especially pp. 162-76 and 187-210.) 

^ For a statement of the effects of open-air schools upon growth 
rate, nutrition, and the composition of the blood, see Health Work 
in the Schools, by Hoag and Terman. Houghton Mifflin Company. 



166 THE HYGIENE OF THE SCHOOL CHILD 

5. L. W. Hines: "The Effects of Schoolroom Temperature on the 
Work of Pupils." Psych. Clinic, 1909, pp. 106-13. 

6. R. G. Macfie: Air and Health, 1909, pp. 345. 

*7. Reichenbach: "Heitzung u. Liiftung von Schulen." Zt. f. 
Schulges., 1912, Beiheft to no. 8, pp. 28-59. 

*8. Steinhaus: "Beitrage zur Frage der Ventilation von Klassen- 
raumen." Zt. f. Schulges., 1913, pp. 6-32. 

*9. F. Verzar: "The Influence of Lack of Oxygen on Tissue Respi- 
ration." Jour, of Physiol., 1912, pp. 39-52. 



CHAPTER XI 

THE TEETH OF SCHOOL CHILDREN 

The problem 

Dr. William Osler has expressed the belief, that 
more physical degeneracy can be traced to neglect of 
the teeth than to the abuse of alcohol. It is undeni- 
able that it affects directly very many more people. 
Of our twenty million school children, not over one 
or two million are free from dental disorder W some 
kind, and of the remainder of the populjation only a 
negligible minority. 

About one fifth of all the teeth of our school chil- 
dren are diseased. Every day hundreds of thousands 
of these teeth are aching. Dental caries has been 
named by Dr. Jessen "the people's disease"; no 
other is so widespread. 

Diseased teeth are thought to be responsible for 
a vast amount of ill-health, including indigestion, 
anaemia, general debility, mental and physical re- 
tardation, nervousness, and acute infectious diseases. 
Complications with heart and ear are common. Life 
expectancy and industrial efficiency depend in no 
small degree on the condition of the teeth. Moral 
efficiency and the joy of living may depend, directly 
or indirectly, about as much on one's teeth as on 
one's philosophy or religion. Who would not agree 



168 THE HYGIENE OF THE SCHOOL CHILD 

with Don Quixote, that a tooth is worth more than a 
diamond? 

Artificial teeth, to be sure, may be substituted for 
those which nature gave us, but since their mastication 
efficiency has been demonstrated to be only about one 
tenth that of natural teeth, they can hardly be consid- 
ered a satisfactory substitution. 

During the Boer War over 3000 English soldiers 
were invalided home because of defective teeth. Out 
of 23,000 rejected applications for enlistment in the 
British army, 5000 were for defective teeth. In 1906, 
the United States rejected 1000 applicants for the same 
reason. In one year 1845 soldiers in the French army 
were sent to the hospital because of disorders of the 
teeth. Loos examined the teeth of 1000 German sol- 
diers and found an average of 9.6 carious teeth per 
head. Cunningham and Rose found an average of 7.5 
and 6.9 per head, respectively. The German soldiers 
examined by Port had 27 per cent of their teeth dis- 
eased (quoted in 14). These are probably average 
conditions for adults in Europe and America. 

Yet the causes of dental decay are definitely known, 
tangible, and amenable to control. About twenty 
millions of dollars, expended in the right way, would 
put all the teeth of all our school children in order, as 
far as their present state of disease permits; and an 
annual expenditure of fifty or seventy-five cents for 
each child, combined with suitable instruction, would 
keep them so. Dental decay is chiefly a disease of child- 
hood and youth. If kept in repair till the age of 



THE TEETH OF SCHOOL CHILDREN 169 

twenty, the teeth should be sound at sixty. Neglected 
till twenty, teeth with any tendency to decay are be- 
yond hope of salvage. 

What examinations of children's teeth have disclosed 

Two decades ago the mouth of the school child was 
to the average educated person an unknown quantity. 
Even the dentist and physician were not aware of the 
actual conditions except by inference, for the simple 
reason that only 5 or 10 per cent of the children ever 
came to them for examinations. It remained for the 
school doctor and school dentist to ascertain the real 
facts. * 

Examinations of thousands of school children in 
diverse parts of the world have shown that fewer than 
10 per cent of our school children are free from diseased 
teeth or gums, dental caries (decay of teeth) being the 
most common defect. The average school child has 
from three to five decaying teeth. Many investigations 
report as many as 20 to 30 per cent of all the teeth as 
affected. 

Pedley, in England, examined 3800 children, 3 to 16 
years of age, and found 75 per cent with diseased teeth : 
12 per cent of all the teeth needed filling or extraction. 

Rose's statistics include 157,361 children in Baden 
and Thuringen, the proportion with diseased teeth 
running from 79 per cent to 98 per cent. From 16 to 
35 per cent of all the teeth were diseased. 

In nineteen cities of Schleswig-Holstein, where 19,- 
725 children of 6 to 15 years were examined, only 5 



170 THE HYGIENE OF THE SCHOOL CHILD 

per cent were free from dental caries. Only 218 of 
these children had ever been treated by a dentist; a 
little over 1 per cent. 

Dr. Jessen's examination of 10,000 school children 
in Strassburg showed 95,7 per cent of the children to 
have a total of 102,456 decayed teeth; 52,219 teeth were 
missing or beyond repair. Of 646 children of kinder- 
garten age, over 85 per cent had diseased teeth, the 
average number per child being slightly above 4. 

Urighavari's statistics for 1000 Hungarian children 
of 6 to 12 years show 87 per cent with defective teeth: 
22.5 per cent of the milk teeth were defective and 7.75 
per cent of the permanent. 

In Cambridge, England, Dr. Cunningham reports 
less than 2 per cent of about 3000 children free from 
dental caries. One third of these children had free pus 
in the mouth from diseased gums or teeth. The Brit- 
ish Dental Association found only 1508 sets of good 
teeth among 10,500 children, while the average number 
of unsound teeth per child exceeded 3 J. Wallis reports 
that London school children average 3.9 carious milk 
teeth and 2.8 carious permanent teeth per child; and 
that 9.3 per cent of London's school population suffer 
from alveolar abscess (*'gum boil"). 

In New South Wales, Australia, 7600 children 
showed 15 per cent of the permanent teeth in a carious 
condition, and 32.5 per cent of the milk teeth. The 
average number of carious teeth per child was 4.5. 

In New York City 61 per cent of 266,426 children 
examined had defective teeth, but less than one fourth 



THE TEETH OF SCHOOL CHILDREN 171 

had ever entered a dentist's office. The Dental Asso- 
ciation in Cleveland found 15,061 cavities in the teeth 
of 2677 children, or an average of 5.6 per child. Boston 
reports 33,575 school children as in need of dental serv- 
ices, and Brookline 77 per cent. Of 500 New York 
children who in 1909 applied for certificates permitting 
them to leave school to go to work, 486 had 2808 de- 
cayed teeth; only 5 per cent had ever visited a dentist 
except for an extraction; and there was not one "de- 
cently clean" mouth in the 500 (22). 

Smaller cities have given similar results. Superin- 
tendent Johnson reports dental caries in 96.9 per cent 
of 497 children of Andover, Massachusetts, aiM 31.4 
per cent of all the teeth as affected: 22.5 per cent of the 
children had suffered from toothache within the previ- 
ous week. Superintendent Reavis examined 407 chil- 
dren in Oakland City, Indiana, and found only 53 with 
satisfactory teeth — 210 children had from 1 to 4 de- 
cayed, and 133 from 5 to 10; 44 children had all four 
of the six-year molars in a carious condition. 

Additional investigations are summarized in the 
table on page 172. 

Our estimate of 90 per cent with one or more defec- 
tive teeth is therefore conservative. When medical 
inspectors (as contrasted with dental examiners) re- 
port only 40 to 60 per cent with defective teeth, we are 
to understand that such low figures are the result of 
superficial inspection without probe and mirror. It 
should be remembered that when the defect has pro- 
gressed so far as to be obvious at a hasty glance, the 



172 THE HYGIENE OF THE SCHOOL CHILD 

TABLE 21 



Date 


Place 


Per cent with 
diseased teeth 


Per cent of all 
the teeth defective 


1902 
1894 


Aschaffenburg 
Berlin 


99 
99 


33 
31 


1897 
1897 


Freiburg 
Halle 


98 
94 


22 


1898 


Hannover 


89-93 


27 


1893 
1902 


Wurzburg 
Rudolstadt 


81-85 
93 


15 

28 


1904 


Augsburg 


99.4 




1900 


Denmark 


92 


21 


1897 
1898 
1902 


Italy 

Norway 

Russia 


92 
91 

82 


14 


1895 


Sweden 


86-100 


16-36 


1900 


Switzerland 


90-100 


14-35 



most favorable time for repairing the injury has gone 

by. 

Other conditions very common are protruding 
upper or lower teeth, jaws meeting at front or back 
only, teeth in double rows, crowded, etc. As Gant 
shows, there is more or less gum disease in one mouth 
out of three, and badly diseased gums in one out of 
twenty. Uncleanliness is very general, and but a small 
minority have ever consulted a dentist for any other 
treatment than extraction. 

Johnson's description (18) of the average school child 
of Andover fits a large proportion of children in every 
school. "He has twenty-four teeth; eight of them are 
diseased; sixteen of them are discolored with unsightly 
accumulation of food and deposits, or else he has some 
noticeable malformation interfering with mastication; 
three of the four six-year molars are seriously affected, 



THE TEETH OF SCHOOL CHILDREN 173 

or else one is already lost and another decayed. He 
has never put a toothbrush to his teeth, has had 
toothache more or less during the past year, and has 
never seen the inside of a dentist's office." 

Age differences are marked. Owing to the approach- 
ing secondary dentition, more diseased teeth are found 
in the lower than in the intermediate grades. The 
smallest number is found at about ten years. In New 
York the ages below ten averaged one third more 
carious teeth than the ages above ten. By the age of 
fourteen, however, so many of the permanent teeth are 
decayed that the number of defective teeth per child 
is as great as at six or seven. The six-year molars as a 
rule begin to decay within two years after their appear- 
ance, so that by the age of ten years one or more of 
them are unsavable. 

No sex differences worthy of note have been made 
out except that the girls are slightly more precocious in 
dentition, having, after the age of six years, an average 
of one more permanent tooth than boys of the same age. 

Injuries produced by defective teeth 

Defective teeth may affect the health of the entire 
body. The influence is chiefly of four kinds: (1) De- 
creased power of mastication, due either to decay or 
irregularities of the teeth; (2) the toxic effect of pus 
which is absorbed directly into the blood or taken into 
the stomach and intestines; (3) reflex nervous dis- 
turbance due to pain, impaction of teeth, etc. ; and (4) 
the possibility of acting as a breeding-ground and 



174 THE HYGIENE OF THE SCHOOL CHILD 

distributing-point for the bacteria which cause acute 
infectious diseases. 

Thorough mastication is prevented by defective 
teeth. This is due to lack of chewing surface, to irreg- 
ularities which prevent the teeth from meeting evenly, 
and to local tenderness. Many children from 6 to 12 
years are deprived of half the normal chewing surface. 
The loss of one tooth always means the functional loss 
of its opposite. Malformation of the jaws, as in severe 
cases of adenoids or impaction (crowding), makes 
mastication practically impossible for many children. 

Mastication has a larger function than merely to 
prepare the food for swallowing. When thoroughly 
performed it trebles or quadruples the amount of 
saliva, mixes it thoroughly with the food, and initiates 
one of the essential processes of digestion, the conver- 
sion of starch into sugar. This is the only part of 
digestion over which we have direct voluntary control. 

Mastication also provides a necessary stimulus for 
the healthy development of the jaw and the growth of 
the teeth. It has been shown experimentally with rab- 
bits that filing the teeth on one side, so as to confine 
mastication to the other side, causes maldevelopment 
of the jaws and of the bones about the nose and the 
base of the skull. Finally, when mastication is thor- 
ough, the teeth tend to clean themselves during the 
meal; when food is bolted the teeth are more prone 
to decay. 

Toxaemia from the swallowing and absorption of pus 
is probably the most serious evil of neglected teeth. 



THE TEETH OF SCHOOL CHILDREN 175 

Every cavity becomes filled with a mixture of decayed 
food and bacteria. Miller has segregated and identi- 
fied more than one hundred different kinds of mouth 
bacteria, several of which are known to be injuri- 
ous. 

The germs of tuberculosis and diphtheria are often 
found in dental cavities and are thought sometimes to 
find their way into the body from this point. Decayed 
and neglected teeth may in this way cause tubercu- 
losis, scarlet fever, diphtheria, etc. When the teeth are 
decayed, the tonsils are also more likely to become dis- 
eased. Gibson found that 1.8 per cent of the children 
with sound teeth had enlarged tonsils; 3.7 pe% cent of 
the children with 1 to 4 carious teeth; and 5.3 per cent 
of those with 4 or more. 

The following table of results from Brown's investi- 
gation confirms Gibson's conclusions (2). 



TABLE 22 



Number of 
carious teeth 


Number of 
children 


Percentage with ton- 
sils enlarged beyond 
size of a filbert 



1-4 

over 5 


1803 
3502 

1678 


7.5 
12.5 
16.2 



When the decay has spread well into the interior of 
the tooth, there is always danger that the pus will find 
its way down through the small opening to the point 
of the root and there cause the infection commonly 
known as an alveolar abscess ("gum boil," or "ulcer- 
ated tooth"). As shown in the accompanying illustra*- 



176 THE HYGIENE OF THE SCHOOL CHILD 

tion, decay causes the death of the tooth, gangrene of 
the pulp, and discharge of pus through the root. This 
infects the surrounding tissues, causing soreness of the 
tooth and jaw, until finally the abscess breaks through 
to the surface of the jaw and allows the pus to escape. 
A sinus remains, however, which continues to discharge 
more or less pus as long as the tooth remains, or until 
it is hollowed out, disinfected, and filled (22). This 
chronic stage may cause no observable symptoms in 
the mouth, but the pus constantly finds its way into 
the remainder of the alimentary tract and into the 
blood. 

Pedley says that the only fit analogy to the chronic 
gum boil is the serpent's tooth, through the hollow of 
which the deadly venom is injected into the flesh of its 
victim. If there is pus in the mouth arising either from 
decayed teeth or diseased gums, some of it will be 
mixed with the food during the process of mastication 
and swallowed. The constant absorption of millions of 
virulent bacteria causes a septic condition of the intes- 
tines, resulting in irritation of the intestinal linings, 
catarrh, diminished secretions, anaemia, and general 
weakness. The bacteria may be carried by the blood to 
distant parts of the body, giving rise to glandular dis- 
turbances, inflammation of the heart, etc. The child 
with extreme oral sepsis is likely to be sallow, thin, and 
nervous. 

The statistics indicate that more than 1 per cent (a 
quarter-million) of our school children are constantly 
suffering from one or more ulcerated teeth. Pus may 




BLOOD I 
VE5SEI 

TO POL 



BLOOO 



"H) CUM 



MAIN BLOOD VESSEL 





THE PHENOMENA OF DENTAL CARIES AND THE DEVELOPMENT OF 
AN ABSCESS (Pedley and Harrison) 

A. Normal tooth tissues with commencing caries at A. 

B. Cavity formed through enamel into dentine by means of acid bacteria. Irri- 
tating pulp and causing swelling of the blood vessels, inflammation and pain. 

C. Death of the blood vessels and infection of the pulp cavity with septic germs 
from the mouth. Inflamed vessels around raising tooth in socket. Pain on biting. 

D. Opening into pulp cavity plugged with food or ddbris preventing escape of 
decomposing gases at A and forcing a passage at B forms an abscess which dis- 
charges at C as a gum-boil. 



THE TEETH OF SCHOOL CHILDREN 177 

arise also from other affections of the gums and teeth, 
and is sometimes found free in the mouths of 30 per 
cent of the school children (8). 

Bad teeth may cause nervousness either indirectly by 
causing malnutrition or directly from the reflex irrita- 
tion which aching or crowded teeth produce. Motor 
automatisms sometimes result and moral self-control 
may become impossible. Even choreiform movements 
and epileptiform seizures may occur. Dr. Jessen exam- 
ined the teeth of 31 stammerers and stutterers and 
found nearly twice the usual amount of defectiveness 
(14). 

Another investigator ^ examined 58 persons \lrith the 
skiagraph (an instrument for recording irregularities 
of the teeth) and found that all who suffered impaction 
showed signs of nervous disorder. The symptoms 
ranged from headaches and restlessness to epilepsy, 
and from mild insomnia to dementia proBcox. The same 
author reports that six out of eight such cases recov- 
ered upon relief of the impaction. It is significant that 
in no case was there any local pain, and in only a few, 
pain of any kind. 

Holmes (12) describes an interesting case of moral 
delinquency and nervous instability which appeared 
to be the result of impacted teeth. The boy became 
irritable, nervous, and restless, gradually developing 
incorrigibility and habits of lying and stealing. He 
was brought before the juvenile court, treated for 
adenoids, etc., to no avail. Finally a dental examina- 
1 See Monthly Cyclop, and Med. Bull., November, 1909. 



178 THE HYGIENE OF THE SCHOOL CHILD 

tion was made which disclosed an extraordinary condi- 
tion of impacted teeth. Treatment was followed by 
return to nervous control and complete moral reform. 
While it cannot be denied that suggestion may have 
been partly responsible for this reform, much clinical 
evidence has been adduced to show that reflex irrita- 
tions may be caused by defective teeth. As for tooth- 
ache, every one recognizes the havoc it may wreak in 
a few hours on the moral habits of a lifetime. 

Defective teeth and mental development 

On classifying his pupils as bright, average, or dull, 
Johnson found that among the children with good 
teeth there were 13 bright children to 10 dull, while 
among those with bad teeth there were only 8 bright 
children to 12 dull. In New York, Ay res found that 
among 3304 boys 10 to 14 years of age 42 per cent of 
the dullards had defective teeth, 40 per cent of those 
with average intelligence, but only 34 per cent of those 
classed as bright. The average progress made in a 
given period by the children with good teeth was 4.94 
years, and by children with defective teeth 4.65; a loss 
of about 6 per cent. Dr. Edwin Collins ^ had already 
claimed a positive correlation between good teeth and 
scholarship, but offered little data in support of his 
argument. 

The problem involved is one whose solution de- 
mands carefully planned research. Only one investiga- 
tion of this type is available on the issue in question, 
1 See Nineteenth Century, July, 1899. 



THE TEETH OF SCHOOL CHILDREN 179 

the Cleveland study undertaken by Dr. Wallin and 
the Oral Hygiene Committee of the National Dental 
Association (33) . The investigation proposed to meas- 
ure by means of suitable tests the influence of proper 
care and treatment of the teeth upon the improvement 
of mental capacities in school children. Forty pupils, 
''repeaters," were chosen for the tests. The teeth were 
first put in order and the pupils were pledged to carry 
out a prescribed regimen of mouth cleanliness and 
thorough mastication. A prize was stipulated for all 
who lived up to the rules, and those who became care- 
less were dropped from the test group. The fidelity of 
the pupils in following instructions was checl^d up by 
a visiting nurse. Twenty-seven pupils were available 
for the entire experiment, which extended over the 
period of one year. The pupils were first tested in 
May, 1910, before dental treatment began; at the 
opening of school in September; and again in May, 
1911. The functions tested involved (1) visual memory 
(reproduction method) ; (2) rapidity of thought (verbal 
associations) ; (3) speed and accuracy in adding digits ; 
(4) association as measured by the '*opposites" test; 
and (5) speed and accuracy of visual discrimination 
(*' A- test "). At the close of the year the pupils showed 
a fairly uniform improvement in all the tests of approxi- 
mately 50 per cent. Improvement in school work was 
simultaneous, only one of the twenty-seven pupils fail- 
ing of promotion. This is an excellent record, consider- 
ing that the pupils tested belonged to the retarded 
class. 



180 THE HYGIENE OF THE SCHOOL CHILD 

A serious defect of Wallin's study, however, lies in 
the fact that no "control" group v/as tested. It is 
therefore impossible to say how much of the observed 
improvement was due to improved adjustment to the 
later tests, how much to the added year of age, and 
how much to the dental treatment and mouth hygiene. 
Nevertheless, it is significant that improvement in 
school progress occurred simultaneously with improve- 
ment in the tests. Other investigations of this type 
should be made under better controlled conditions. 

Effects upon health and growth 

It has been noticed by several investigators that 
children with bad teeth are extremely likely to be 
below normal size. Johnson found children with good 
teeth to average one half-year ahead of children of the 
same age whose teeth were bad. Wallis (34) says that 
he has found children with severe oral sepsis (discharge 
of pus) nearly always under weight and frequently 
below grade. Henneberg (11) found that children with 
good teeth gained 5 per cent more in weight and nearly 
10 per cent more in height during one school year than 
children with bad teeth. The following are typical 
cases described by Colyer (4, p. 168 ff .) : — 

(1) A girl of 4| years, considerably below normal weight, 
was suffering from severe gastro-intestinal trouble. Several 
decayed teeth were filled or removed, following which the 
girl gained four pounds in four months, or twice the normal 
gain for the age in question. (2) A girl of three years weigh- 
ing 24 pounds developed tenderness of the teeth and lost 1| 



THE TEETH OF SCHOOL CHILDREN 181 

pounds in one month (February). The deciduous molars 
were removed and local treatment applied to the incisors. 
Within one month the child increased 2| pounds. By Sep- 
tember 3, the weight was 27§ pounds. The incisors now be- 
gan to give trouble, and the child was seen October 6, when 
its weight had fallen to 25f pounds. Attention to these teeth 
was followed by progressive and normal increase in weight. 

Only two or three studies are available which fail to 
support the usual medical opinion that defective teeth 
are injurious to health. One of these was an investiga- 
tion made by the school doctors of Magdeburg, Ger- 
many, in 1910-11, and reported by Dr. Henneberg 
(11). The procedure in the experiment consisted in 
selecting from each schoolroom five poorly nourished 
and ^ve well nourished children and subjecting them 
to dental examination, to measurement of height, 
weight, and chest girth, and to year-long observation 
for contagious disease. On the basis of his own 150 
cases Henneberg denies any significant relationship 
among the traits in question and states that the other 
22 school doctors were led to the same conclusion. 

For two reasons, however, the conclusions of the 
Magdeburg school doctors do not seem warranted by 
the data of the investigation. In the first place, they 
ruled out of the investigation (1) all children from the 
poorest homes; (2) all of tubercular heredity; (3) all 
vacation colony children (the pre- tuberculous) ; and (4) 
those subject to frequent illness. These four classes 
are, of course, just the ones in whom the extreme influ- 
ences of defective teeth are most likely to be detected. 



182 THE HYGIENE OF THE SCHOOL CHILD 

In the second place, their data do show certain sig- 
nificant differences. Of the badly nourished, 61 per 
cent had "bad" teeth (four carious teeth, or more); of 
the well nourished, only 52 per cent. Bad teeth were 
therefore more than one sixth less frequent with the 
well nourished. During the year children with good 
teeth gained an average 5 per cent more in weight and 
10 per cent more in height than those with bad teeth. 
On selecting the 22 children having the very worst 
teeth and comparing them with the 22 having the 
very best, the following important differences were 

found : — 

TABLE 23 





Poorly nourished 


Well nourished 


With worst teeth (22) 
With best teeth (22) 


9 
14 


13 
8 



Of the children 38 were suffering from marked anae- 
mia, and of these 28 had "bad" teeth and only 10 had 
"good" teeth. The actual correlation is too obvious 
to require further comment. 

Dr. Henneberg's conclusion, denying any relation- 
ship, seems to rest on the erroneous premise that if 
such a correlation existed it would hold for every in- 
dividual case, and that the child with poor teeth would 
always be found inferior in nutrition, height, weight, 
blood composition, susceptibility to contagious disease, 
etc. Such, however, would be the case only if bad teeth 
were the sole cause of the defective conditions named. 
This, of course, is maintained by no one. In reality the 
data should be interpreted as supporting, rather than 



THE TEETH OF SCHOOL CHILDREN 183 

discrediting, the conclusions which have resulted 
from clinical evidence against defective teeth. 

On the other hand, we must avoid attributing to 
defective teeth conditions which are due to other 
causes. Thiele's examinations of 1500 children enter- 
ing school in Chemnitz (Germany) showed that chil- 
dren classed as having "unsatisfactory'* teeth (four or 
more defective) did not differ materially from those 
having "satisfactory" teeth (less than four defective) 
as regards nutrition, rickets, tuberculosis, adenoids, 
heart defects, discharging ear, or speech defects (30). 

Dr. Ernst's study of the dental conditions of 500 
boys entering school in Kiel (Germany) also gaire little 
correlation between the condition of health and the 
number of carious teeth except when the latter num- 
bered nine or more. Ernst agrees with Henneberg that 
in such cases the decayed teeth are less the cause than 
the result of low general vitality (7). 

A complete reinvestigation of the problem^ is ur- 
gently needed. In further studies of this type, the 
classification of pupils according to dental defective- 
ness should be made on a finer scale. Classification 
into two groups only, those with "good" teeth and 
those with "bad," is needlessly coarse for statistical 
purposes. 

The cause of dental caries 

The salient facts of dental caries have been suc- 
cinctly stated by Pedley and Harrison (23, pp. 75-76) 
as follows : — 



184 THE HYGIENE OF THE SCHOOL CHILD , 

1. Dental caries always commences on the outside, and is 
due to external causes. 

2. Fermentation and putrefaction of particles of food are 
effected by the ever-present bacteria, and this involves the 
production of acids. 

3. The enamel is attacked at one spot, some places being 
more vulnerable than others, especially in crevices where 
food has the opportunity of resting., 

4. The enamel prisms are split up and disintegrated. 
When the dentine is reached, the acid-forming bacteria dis- 
solve out the lime and leave a softened area. 

5. The dentinal tubules are invaded, and they become 
swollen and dilated. 

6. Liquefying bacteria dissolve the tubes and the gelat- 
inous matrix. 

7. Further disintegration of enamel, with dissolution of 
the dentine, leads to the formation of a cavity, in which 
food and bacteria find a resting-place. 

8. Gradually the pulp is infected. 

9. Owing to inflammatory action, the nerve tissue is irri- 
tated, the blood pressure is increased, and the vessels be- 
come dilated. 

10. Pus appears in isolated spots, and the whole tissue 
dies. 

11. This is followed by decomposition and putrefaction. 

12. When this septic material is forced through the root 
an abscess (gum boil) is the result, accompanied with fever 
and general malaise. 

The mouth is an ideal culture medium for germ life 
because of the warmth, moisture, and nutritive ma- 
terial afforded. Streptococcus and staphylococcus, 
both pus producers, are always in the mouth. Pneu- 
mococcus (the germ causing pneumonia) and the tu- 



THE TEETH OF SCHOOL CHH^DREN 185 

bercle bacillus are frequently found. On the basis of 
partial counts it has been estimated that a moderately 
unclean mouth may harbor more than a billion bac- 
teria. 

The enamel and dentine are not broken down by the 
bacteria directly, but by the acids produced by the 
action of bacteria upon the food particles left in the 
mouth. The problem, therefore, is the prevention of 
acids. The saliva, which is slightly alkaline, helps to do 
this. In ill-health, however, the saliva may lose part or 
all of its neutralizing power; and what is still more im- 
portant, food remnants that are left thickly plastered 
in the recesses of the teeth protect a part of the^eposit 
from the effect of the saliva and so permit the destruc- 
tive processes to begin. Recessive gums, mouth breath- 
ing, and accumulations of tartar have also this effect. 

The rate of acid formation depends in part upon the 
nature of the food particles left in the mouth, the car- 
bohydrates being the foods which most readily ferment 
and produce acids. For this reason a meal should not 
end with jams, jellies, cake, candy, or other foods rich 
either in starch or sugar, nor should these be eaten 
between meals. When sweets are eaten, they should be 
followed by solid foods, such as apples, which have a 
cleansing effect. The high susceptibility in this coun- 
try to dental caries may be partly accounted for by the 
fact that our sugar consumption per capita is by far 
the highest in the world. ^ 

^ Merritt gives this as 92 1 pounds per capita, or 15 pounds higher 
than our closest competition. 



186 THE HYGIENE OF THE SCHOOL CHILD 

Whatever the food, the essential problem is that of 
keeping the mouth clean. The main obstacles to this 
are three: (1) dental irregularities; (2) the use of soft, 
sloppy, or pasty foods; and (3) insufficient mastication. 
Wallace (32) has convincingly shown that even, well- 
matched teeth clean themselves in the thorough mas- 
tication of solid foods, and that they do this more effec- 
tively even than the toothbrush. If the food is pasty, 
however, mastication plasters it so tightly against the 
teeth that no ordinary amount of brushing removes it. 
Wallace believes that the choice of solid food and its 
deliberate mastication are more important preventive 
measures than any amount of artificial cleanliness. 
His opinion is based on over 6000 experiments made for 
the purpose of determining differences in the tendency 
of different foods to lodge in the mouth. 

In order to try the theory, Wallace secured parental 
cooperation in subjecting fourteen children to a test. 
From the age of three or four years they were given 
foods of high tooth-cleansing power and were required 
to masticate thoroughly. After each meal the mouth 
was rinsed. At the age of five to seven years not one 
of the children had a carious tooth. 

When a tooth is sore, mastication is shifted to the 
other side of the mouth or else slighted altogether. 
The teeth consequently do not clean themselves, par- 
ticularly on the involved side, and caries results. 
Moreover, as already pointed out, deficient mastica- 
tion leads to maldevelopment of the jaws and result- 
ing dental irregularities. This, in turn, adds another 



THE TEETH OF SCHOOL CHILDREN 187 

obstacle to thorough mastication and hinders the self- 
cleansing process. Decay once started tends to spread 
to adjacent teeth mainly for the reason that the sore- 
ness interferes with mastication on the involved side 
and the teeth of that side become clogged with food 
remnants. 

[ It is largely for the above reasons that the care of 
the temporary teeth is so important. When neglected, 
as they usually are, thorough mastication is out of the 
question and the jaws do not properly develop. The 
palate tends to become arched, and the permanent 
teeth are almost sure to come in crowded or uneven. 
Wallace even believes that irregular teeth an(^ arched 
palate are more the cause of adenoids than their result, 
and that if larger use were made of solid foods, if mas- 
tication were always thoroughly performed, and if the 
temporary teeth were carefully preserved, adenoids 
would rarely develop. 

At any rate, irregularities of the teeth are known to 
be extremely productive of caries and should always be 
corrected. It is estimated that about 80 per cent of 
adults have one or more dental irregularities predispos- 
ing them to caries. Pits and crevices in the teeth, 
however caused, act as lodging-points for food, are 
diflScult to cleanse, and are therefore always the start- 
ing-points for decay. 

Thus far we have considered the immediate cause, the 
presence in the mouth of acid-forming bacteria. An- 
other factor of great importance is the tooth's power of 
defense. If the enamel is thin or defective in structure. 



188 THE HYGIENE OF THE SCHOOL CHILD 

disintegration is made easy. It is well known that 
individuals differ enormously in their natural resist£ince 
to dental caries. Some teeth remain perfectly sound 
without the slightest care; others require all the arts of 
dentistry to hold them together. We must consider, 
therefore, the tooth's nutrition. 

Both sets of teeth are formed and embedded in the 
jaw long before the end of pre-natal life. When the 
milk teeth are beginning to appear, the enamel of the 
permanent teeth is already developing. As far as is 
known, enamel once formed changes little for better or 
for worse from natural causes. We must go through 
life with our original dental armaments. There is no 
second dispensation.^ When nutrition is insufficient 
during infancy and childhood, the teeth are very likely 
to be imperfect. Growing cells cannot build a perfect 
structure without suitable material. 

The main cause of infantile malnutrition is artificial 
feeding. Michael^ investigated the relation of dental 
caries to infant feeding in 11,762 children. Those who 
had been suckled ten months or more had only 9 per 
cent of their teeth carious; those fed on cow's milk, 22 
per cent; those whose principal diet was oatmeal water, 
27 per cent. Children suckled six months had teeth 
correspondingly inferior to those suckled ten months. 
Rose's study of 157,000 children shows the same thing. 
Even the mother's milk is sometimes inferior, due to 

1 While this is certainly true in the main, some authorities make 
allowance for the possibility of slight physiological changes in the 
enamel after the tooth hasS attained its growth. 

2 Quoted by Colyer. 




THE REPLACING OF THE TEMPORARY TEETH 

Showing the rudimentary permanent teeth embedded below the roots of the temporary 

teeth 
From A Handbook of Health, by Woods Hutchinson, M.D. Houghton Mifflin Company, 

publishers 





BEFORE AND AFTER 

Plaster of Paris casts showing results of orthodontia 

(Courtesy of Dr. C. S. McCowen, Palo Alto, Cal.) 



THE TEETH OF SCHOOL CHILDREN 189 



worry, overwork, alcoholism, specific disease, etc. 
Jewish children, who as a rule are breast-fed and other- 
wise well cared for, are much less subject to dental 
caries than other children (23). 

Thv) following table from Ernst (7) shows the strik- 
ing correlation between the number of carious teeth in 
children entering school and infant malnutrition : — , 

TABLE 24 



Breast- 
fed 
12 mos.-|- 



Rickets 


Bottle 
children 


Breast- 
fed 
3 to 6 


Breast- 
fed 
6 to 9 


Breast- 
fed 
9 to 12 






mo3. 


mos. 


mos. 



Number of carious 

teeth 

Per cent of children 

with perfect teeth 
Distribution of 

those with nine or 

more carious 

teeth 



8.25 


6.25 


4.8 


4. 


3.3 '► 


0, 


1.14% 


6.63% 


16.% 


16.4% 




64. % 


22. % 


22.% 


14. % 



3. 
21.3% 

14. % 



Since the enamel of the permanent teeth is in process 
of formation throughout the early years of childhood, 
temporary disturbances of nutrition, such as measles, 
scarlet fever, etc., often leave horizontal rings of micro- 
scopic pits around the enamel. 

Rose finds a correlation between the prevalence of 
dental caries and lime deficiency in the soil. In regions 
with least lime, caries was present with from 98 to 98.7 
per cent of the children; where the proportion of lime 
was greatest, the number affected ran as low as 79 to 
82.8 per cent (27). 

Rose and Underwood have demonstrated the closest 
relation between dental caries and the degree of civili- 



190 THE HYGIENE OF THE SCHOOL; CHILD 

zation. All primitive races are practically immune, 
regardless of food habits and of habitat. Native 
Africans are practically immune, also Eskimos. The 
former clean their teeth religiously after each meal, the 
Eskimos never. Natives of India, Malays, and Austra- 
lians are also little affected. 

It has not been demonstrated, however, that the 
difference is one of racial heredity. From an examina- 
tion of many skulls. Underwood shows that dental 
caries is ten times as prevalent in western Europe to- 
day as it was one hundred years ago. European skulls 
of the eighteenth century average about one decayed 
tooth each; those of to-day about ten. Smith (31) 
examined over 50,000 Egyptian skulls and found prac- 
tical immunity up as far as 4000 B.C.; after that a rapid 
increase. Of 500 "aristocratic" skulls dating from the 
pyramid epoch, only 50 were free. 

It hardly seems possible that actual racial degener- 
acy as regards the power of the teeth to resist decay 
could establish itself so universally in a few genera- 
tions. Nor is it necessary to assume such degenera- 
tion. Underwood, who has made the most extensive 
researches in this field, holds that the facts are readily 
explained in terms of changed food habits. Cooked, 
mushy, and sticky foods have replaced foods that were 
resistant and fibrous. The consumption of sweets has 
been multiplied many times. Mastication can more 
easily be slighted. This tends to produce irregularities 
of the teeth and maldevelopment of the jaws. Babies 
are less often nourished in the natural way, and all 



THE TEETH OF SCHOOL CHn^DREN 191 

through childhood there is a deficiency of the sunlight, 
air, and activity necessary to healthy growth. The 
disease is a disease of civilization. 

For these and other reasons, the prevention of dental 
caries is becoming a more difficult problem than ever 
before. If the disease is not arrested, micro-organisms 
will soon score their first complete victory. 

Prevention 

Appropriate preventive treatment during childhood 
would probably insure good teeth to a majority of 
adults. Preventive measures should include especially 
cleanliness, thorough mastication, suitable fo%d, the 
care of the temporary teeth, nutrition during infancy 
and childhood, the prevention of decay, the preven- 
tion of irregularity, and the repair of defects as rapidly 
as they appear. To this end the school can make two 
contributions of the greatest importance: (a) It can 
instruct children more thoroughly than it now does in 
the essentials of mouth hygiene; and (6) it can under- 
take preventive and curative treatment in school den- 
tal clinics. 

(a) The teaching of mouth hygiene. The common 
practice among authors of textbooks in physiology and 
hygiene, of dismissing the subject of teeth with a page 
or two, touching mostly on their anatomy, is indefen- 
sible. Instead of such summary treatment the whole 
subject should be thoroughly canvassed. The brief 
presentation of a few essential facts relating to their 
anatomy should be followed by a fuller discussion of 



192 THE HYGIENE OF THE SCHOOL CHILD 

the importance of good teeth for health, the causes of 
dental decay, and the means of its prevention. The 
instruction should be extended over several years, and 
liberal use should be made of plates, wall charts, and 
illustrative material. Health rules for the teeth could 
well be pasted in the backs of all schoolbooks. 

Special effort must be centered on making the instruc- 
tion carry over into action. Health instruction with- 
out health habits is vain. Children should be taught in 
the school how to rinse the mouth, to gargle, and to 
brush the teeth. Actual drills for this purpose are to 
be commended. The sentiment of disgust may be 
advantageously enlisted in the interest of mouth clean- 
liness. 

Factors which influence the growth and decay of the 
teeth in infancy cannot, of course, be reached directly 
by the school. They may be reached indirectly, how- 
ever, by the education of girls and young women for 
the duties of motherhood. 

(b) The school dental clinic. The school should offer 
treatment as well as instruction. The universal preva- 
lence of dental caries has been sufficiently shown; like- 
wise that it is folly to expect the parents of to-day to 
deal adequately with the problem on their own initia- 
tive. Parents, unfortunately, are too likely to be satis- 
fied as long as the tooth does not ache. It is an excep- 
tional father who knows what the lips of his children 
conceal. Thousands of them have never essayed a 
glance into the interior of the mouth they work so 
devotedly to feed. In the most aristocratic suburb of 



THE TEETH OF SCHOOL CHILDREN 193 

Boston 75 per cent of the children had never been to 
a dentist. Not over 5 per cent of the children in the 
United States regularly receive the dental treatment 
they need. Even physicians are likely to neglect their 
opportunities to give advice about the care of the teeth. 

The six-year molars are especially subject to decay 
and are usually mistaken by parents for temporary 
teeth. Consequently they are usually neglected till the 
day of salvage has gone by. Dr. Mary Gallup, of 
Boston, examined the mouths of 3000 adult Americans 
and found only 7 complete sets of six-year molars. Dr. 
Henie, of Norway, found over 40 per cent of the six- 
year molars diseased by the end of the eighth ^ar and 
60 per cent by the end of the fifteenth year.^ 
[ In fact, there is no other matter of health where the 
proverbial ounce of prevention will go so far. Dental 
caries is a disease of childhood and youth. "The per- 
son whose teeth are neglected till the age of twenty is 
already a lost cause." "When a tooth has ached, the 
best time for saving it has gone by." To preserve in a 
sound condition the teeth of an entire family costs no 
more than the belated treatment of a single tooth. To 
insure the necessary treatment no other means is as 
cheap or effective as the school clinic.^ 

Finally, orthodontia ^ should be encouraged. There 
is no reason why the child's health should be jeopard- 

^ Quoted by Burnham. 

2 For a discussion of school dental clinics see Health Work in 
the Schools, by Hoag and Terman. Houghton Mifflin Co. 

' The mechanical treatment of dental irregularities and deformi- 
ties of the jaw. 



194 THE HYGIENE OF THE SCHOOL CHILD 

ized and his face made repulsive just because his 
parents lack the knowledge or the money to remedy the 
defect. Nothing in the way of dental irregularity is bad 
enough to be hopeless if taken in hand early enough. 
A little girl known to the writer had at the age of ten 
years the facial appearance of an idiot. The palate 
was arched high and pointed at the front like the letter 
V. The upper teeth, already projected beyond the lips, 
were so crowded that one appeared entirely within the 
V. The child suffered constantly from indigestion and 
headaches. Four years of orthodontia transformed the 
repulsive face into one of absolutely normal appear- 
ance and brought every tooth to its proper position. 
The anaemia and headaches disappeared simulta- 
neously. The plate facing page 188 illustrates the mira- 
cles that are constantly being wrought by orthodontia. 

Some indications of dental defects 

Unclean-looking teeth. 

Unsound-looking teeth. 

Unhealthy-looking gums. 

"Gumboils." 

Crooked teeth. 

Prominent teeth. 

Offensive breath. 

Toothache. 

Admission of never having been treated by a dentist. 

Neglect of daily use of toothbrush. 

Headache. 

Enlarged lymph glands in the neck. 



THE TEETH OF SCHOOL CHILDREN] 195 

Indigestion. 

General malnutrition.^ 

REFERENCES 

1. W. H. Allen: Civics and Health. (Chap, ix.) 

2. H. M. Brown: "The Relationship between Enlarged Tonsils 
and Carious Teeth." School Hygiene, 1913, pp. 24-25. 

*3. W. H. Burnham: "The Hygiene of the Teeth." Ped. Sem., 

1906, pp. 293-306. 
*4. J. F. Colyer: Dental Disease in Relation to General Medicine. 

1911, pp. 190. 

*5. W. S. Cornell: Health and Medical Inspection of School Children. 

1912, pp. 305-23. 

6. George Cunningham: "Dental Conditions in Elementary- 
School Children." In Kelynaek's Med. Insp. of Schools, chap. 

XII. 

7. Dr. Ernst: " Dental Examinations in Kiel Elementary Schools.!* 
Zt. f. Schulges., April, 1912, pp. 241-44. 

*8. A. W. Gant: "Dental Treatment of School Children at Cam- 
bridge." School Hygiene, 1911, pp. 402-11. 
9. Greve: The Prevention of Disease, pp. 267-97, 
10. B. Gutenberg: "Zum Kapitel der Zahne u. Zahnpflege bei den 
Kindern." Zt. f. Schulges., 1901, pp. 452-66. 
*11. H. Henneberg: "Ein Beitrag zur Zahnfrage." Zt. f. Schulges.^ 
1911, pp. 894-911. 

12. Arthur Holmes: "Can Impacted Teeth Cause Moral Delin- 
quency?" Psych. Clinic, vol. iv, pp. 19-23. 

13. W. Hunter: Oral Sepsis as a Cause of Disease. 

*14. Dr. Ernst Jessen: Die Zahnpflege in der Schule vom Stand- 

punkt des Aerztes. 1909, pp. 67. 
*15. Dr. Ernst Jessen: " Schulzahnpflege u. Schule." Proc. Second 

International Congress for School Hygiene, 1907, pp. 495-502. 
16. Dr. Ernst Jessen: "Kostenpunkt einer Stadtischen Schul- 

zahnklinik." Inter. Mag. Sch. Hyg., vol. iv, 1908, pp. 432-38. 
*17. Dr. Ernst Jessen: "Die Zahnarztliche Behandlung der Volk- 

schulkinder." Inter. Mag. Sch. Hyg., 1907, pp. 205-22. 
*18. G. E. Johnson: "Condition of Teeth in School Children." Ped. 

Sem., 1901, pp. 45-58. 

19. E. C. Kirk: "The Dental Disabilities of School Children." 
Psijch. Clinic, 1910, pp. 217-23. 

20. Carl Kuens: " Gaumendefekte u. ihre Behandlung." Zt. f. 
Schulges., 1911, pp. 401-10. 

*21. John S. Marshall: Mouth Hygiene and Oral Sepsis. 1912, pp. 

262. 
*22. Arthur S. Merritt: "Mouth Hygiene and its Relation to 

* The author is indebted to Dr. T. Sydney Smith, of Palo Alto, 
Cal., for valuable suggestions in the preparation of this chapter. 



196 THE HYGIENE OF THE SCHOOL CHILD 

Health." In The Public Health Movement. Published by Am. 
Acad. Polit. and Soc. Sci., 1911, pp. 228-42. 
*23. Pedley and Harrison: Our Teeth: How Built Uj), How Destroyed, 
How Preserved. London, 1908, pp. 97. 

24. W. H. Potter: "The Care of the Teeth of School Children." 
Proc. Am. Assoc. Sch. Hyg., 1912, pp. 159-64. 

25. W. L. Pyle: Personal Hygiene, 1910, pp. 17-25. 

26. W. C. Reavis: "Dental Examinations of School Children." 
The Elementary Teacher, 1910, pp. 90-98. 

27. Karl Rose: "Die Zahnpflege in den Schulen." Zt.J. Schulges., 
1895, pp. 65-87. 

28. Dr. Schlegel: "The Reading (Pa.) Free Dental Dispensary." 
Psych. Clinic, February, 1910. 

29. Spokes: "The Care of the Teeth during School Life." Proc. 1st 
Inter. Cong. Sch. Hyg., vol. iii, pp. 453-61. 

30. Adolf Thiele: "Gebiss u. Korperbeschaffenheit der Schulan- 
fanger." Zt. f. Schulges., 1910, pp. 802-06. 

*31. Arthur S. Underwood: "The Prevalence of Dental Caries in 
Modern Civilized Communities." Nineteenth Century and 
After, July, 1912. 

*32. Sim Wallace: The Prevention of Dental Caries. 1912, pp. 70. 

33. J. E. W. Wallin: "Experimental Oral Euthenics." Dental 
Cosmos, April and May, 1912. "Medical and Dental Inspec- 
tion in the Schools of Cleveland." Psych. Clinic, January, 1910. 

34. C. E. Wallis: "The Teeth of the School Child." School Hygiene, 
1910, pp. 396-99. (See also same volume, pp. 44-46.) 

*35. C. E. Wallis: School Dental Clinics: Their Foundation and Man- 
agement. London, 1913. 

*36. Dr. Wimmenauer: "Schularzte u. Schulzahnhygiene." Zt. f. 
Schulges., 1911, pp. 882-93. 
37. Dr. Wimmenauer u. Dr. Stephani: " Schulzahnklinik oder freie 
Zahnarztwahl." Zt. f. Schulges., 1913, pp. 225-43. 



CHAPTER XII 

THE HYGIENE OF THE NOSE AND THROAT 
Written with the assistance of Dr. E. B. Hoag 

Relation of the nose and throat to health 

The hygiene of the nose and throat during child- 
hood is important for several reasons. In the first 
place, the condition of the respiratory passages deter- 
mines in large measure our susceptibility to many 
infectious diseases. It is now well establisl^d that 
diphtheria, scarlet fever, measles, mumps, whooping- 
cough, infantile paralysis, influenza, ordinary colds, 
pneumonia, and tuberculosis all gain entrance to the 
body in the majority of cases through the nose or 
throat passages. Not only is this true, but the secre- 
tions of these passages are capable of harboring for an 
extended period the organisms of many, if not all, of 
the diseases mentioned. In such cases the individual 
concerned may remain a "carrier" long after he him- 
self has recovered. This fact has not yet been demon- 
strated for all of the above-named diseases, but it has 
been so completely and satisfactorily proved in respect 
to diphtheria, tuberculosis, pneumonia, and infantile 
paralysis that we are justified in the belief that it occurs 
also in others. 

The nose and throat passages are provided by nature 
with certain safeguards against the invasion of disease 



198 THE HYGIENE OF THE SCHOOL CHILD 

germs. These include the tonsils (the pharyngeal tonsil 
or normal adenoid structure of the back part of the 
nose, and the lingual tonsil on the back of the tongue), 
the mucous secretions, the ciliated cells of the epithe- 
lium of the nose and bronchial tubes, and the hairs lin- 
ing the outer portion of the nasal passages. Anything 
that interferes with the health of these passages ren- 
ders the body more liable to infection. Consequently, 
adenoids (overgrowth of the third tonsil), enlarged 
inflamed tonsils, small follicular tonsils, nasal catarrh, 
or obstruction of the nasal passages by means of polypi 
or enlarged turbinates, all tend to break down the 
natural barriers against disease germs. Children with 
adenoids or diseased tonsils nearly always suffer from a 
greater number of children's diseases than do others, 
and it has been observed time and again that such 
children have an increased tendency to tuberculosis, 
either general or lymphatic (i.e., of the lymph glands 
of the neck). The occurrence of cervical adenitis,^ or 
inflammation of the neck glands of a non-tubercular 
character, is frequently observed in connection with 
adenoids or diseased tonsils by every medical officer of 
schools. 

Tonsils in a state of health serve as guardians against 
infection, but diseased tonsils not only lose their power 
to protect the body, but actually harbor disease germs 
and their poisonous products. These facts ought to 
answer, once for all, the question as to the advisability 
of removing diseased tonsils or adenoids. 

While it is well known that inflammation of the 



THE NOSE AND THROAT 199 

tonsils (tonsillitis) produces fever and general disabil- 
ity, it is not so generally understood that both the 
throat tonsils and the third tonsil, or adenoids, may be 
diseased without the knowledge of the patient and 
produce fever and general malaise. This is particularly 
true of adenoids, which are often infected: In such 
cases the cause of the fever and consequent sickness is 
often regarded as obscure, and sometimes the real 
cause is not discovered at all. The intimate relation of 
diseased tonsils and adenoids to the general health of 
the body is most important, while the special relation 
of these structures to acute infections, catarrh, and 
deafness is so important as to demand the utmc^t care. 

In the second place, obstruction of the nasal pas- 
sages forces the individual to "mouth-breathing." 
Why should it be a matter of concern whether one uses 
the mouth or the nose for a breathing-passage .^^ The 
answer is that the nose is much more than a mere tube 
for breathing. It performs at least five important 
functions which the mouth can perform only partially 
or not at all. 

(1) The nose acts as a marvelously elBFective filter, 
clearing the inspired air of nearly all its dust particles 
and germs. This is accomplished chiefly by the ciliary 
projections of the mucous linings, which intercept 
nearly all the small foreign bodies of the air and carry 
them, by means of constant wave motions, to the 
pharynx and mouth, there to be expelled. If the mucous 
membranes are too dry, or if their secretions are not 
normal, as in catarrh, this function of the nose is seri- 



200 THE HYGIENE OF THE SCHOOL CHILD 

ously interfered with. In case of mouth-breathing the 
filtering takes place to only a slight degree. 
\ (2) Due to the shelf-like arrangement of the turbi- 
nated bones, the walls of the nasal passages contain an 
extensive surface of mucous membrane. This is sup- 
plied with a vast system of blood vessels which permit 
the heating of the air in its passage to the lungs. The 
blood sinuses are surrounded by involuntary, erectile 
muscular fibers which work automatically so as to reg- 
ulate the amount of blood in the vessels near the sur- 
face. When we go out into a cold atmosphere the 
amount of blood in these vessels is quickly increased 
to permit the more rapid warming of the air. 

(3) The arrangement just described also makes pos- 
sible the addition to inspired air of a great deal of 
moisture. Air which is received at 20 to 40 degrees 
temperature, and which contains but little moisture, 
is raised almost to body heat and becomes two thirds 
saturated in its passage through a healthy nose. The 
significance of this for health lies in the fact that the 
interchange of gases in the lungs is largely dependent 
upon the temperature and humidity of the air in the 
lung cells. It is estimated that the healthy nose adds 
to the inspired air about one pint of water every 
twenty-four hours. 

(4) The nose is an important organ of phonation. 
When it is obstructed by adenoids, enlarged tonsils, or 
polypi, the resonant chamber is reduced in size, giving 
the thick quality of speech known as the "nasal voice." 
This is due chiefly to the interference caused by nasal 



THE NOSE AND THROAT 201 

obstructions in the formation of overtones. The learn- 
ing of a modern language is made more difficult, and in 
extreme cases certain sounds cannot be produced at all.i 

(5) Mouth-breathing eliminates the sense of smell. 
This sense may have less importance than it once had, 
but is still far from valueless. It not only acts as a 
warning against dangerous gases and impure air, but 
has also an aesthetic value, as Helen Keller has beauti- 
fully shown us. 2 

The hygiene of the nose is important for several 
other reasons. More than half the cases of deafness, 
and most cases of partial deafness, are caused by ob- 
structed breathing. There are probably one pillion 
children in the schools of the United States who are 
hard of hearing from this cause. Earache and ear- 
discharge are nearly always due to infection which has 
spread from an unhealthy nose or throat to the middle 
ear through the eustachian tube.^ Diseased air pas- 
sages also befoul the air of the schoolroom and add to 
the difficulties of school sanitation. 

Finally, and most important of all, mouth-breathing 
lowers mental efficiency, causing apathy, dullness, nerv- 
ous instability, etc., with consequent school retarda- 
tion. That form of inattention resulting from nasal 
obstruction has been given the special name **apro- 
sexia nasalis." 

In a valuable study Kafemann tested the mental 

1 See p. 200. . 

2 Helen Keller, The World I Live In. (Chap, entitled "Smell', the 
Fallen Angel.") 

» See p. 228 /. 



202 THE HYGIENE OF THE SCHOOL CHILD , 

efficiency of two groups of normal subjects, i Those of 
one group had the nostrils artificially closed during the 
test; those of the other group were permitted normal 
respiration. The results proved that artificial stop- 
pages of the nasal passages for even a few hours low- 
ered mental efficiency. 

Enlarged tonsils 

The faucal tonsils are the ones which are ordinarily 
spoken of as "the tonsils," and are situated at either 
side of the root of the tongue. Normal tonsils are 
barely visible, but enlarged tonsils range from the size 
of an almond to that of a large English walnut. It is 
not difficult to see the tonsils if the child will open his 
mouth wide, relax his throat, and take a deep breath, 
or better, pant. A wooden tongue depressor may be 
used to hold down the tongue, but this is not always 
necessary in routine examination after a little skill has 
been acquired in the management of the child. 

The normal tonsils appear as small, oval, smooth, 
pinkish masses of lymphoid tissue. Any marked over- 
growth, holes (crypts), redness, white spots, or irregu- 
larity in structure indicate abnormal conditions. Over- 
growth of tonsils in young children is extremely 
common, and may occur without any other sign of dis- 
ease. In fact, this condition is so common that unless 
it is a fairly severe case many physicians consider it 
best to disregard it. 

Like the lymphoid structures of the neck, the tonsils 
'* The "addition test" was used. 



THE NOSE AND THROAT 203 

are often somewhat enlarged without causing any no- 
ticeable symptoms. The tendency to a small amount 
of glandular enlargement, though not normal, must not 
be unduly emphasized. In many cases such conditions 
tend to disappear spontaneously as the child grows 
older and stronger. On the other hand, it should not be 
forgotten that marked glandular enlargement indicates 
what is called a "lymphatic diathesis," which is a 
serious condition. The presence of a chronic inflam- 
mation always undermines the health more or less. 
Good judgment and experience are required in esti- 
mating the importance of enlarged tonsils, and there is 
probably no other point in the physical examjjiation 
of children on which examiners so greatly disagree. 

Enlarged tonsils are often the index of other bad 
conditions. Many children with enlarged tonsils pre- 
sent also such symptoms as pallor, anaemia, malnutri- 
tion, and enlargement of the cervical (neck) glands. In 
these cases all the lymphoid tissues of the throat and 
neck are likely to be infected, the child's resistance to 
disease is low, and the entire physical organization 
needs building up. 

^ The structures most often affected in children are 
the faucal (throat) tonsils and the post-nasal tonsil, or 
adenoids. Adenoids are only the result of overgrowth 
of the third tonsil, and do not represent a new growth 
in any sense. The faucal and the nasal tonsils are 
structurally similar, being made up of lymphoid tissue. 
Like all other lymphoid tissues, they are much dis- 
posed to hypertrophy (enlargement) during childhood. 



204 THE HYGIENE OF THE SCHOOL CHILD 

The function of the three tonsils is not fully known, 
but it is believed that when healthy they arrest the 
entrance of disease germs into the lymphatic vessels 
and blood stream. Diseased tonsils, on the other hand, 
are thought to act as points of entrance for various 
kinds of infection. It is believed by some of the best 
authorities that rheumatism frequently, if not usually, 
invades the body by this route. At any rate, a previ- 
ous history of tonsillitis is often discovered in cases of 
articular rheumatism. As shown elsewhere (p. 310), 
chorea and heart disease often follow an attack of 
acute rheumatism. Tonsillitis, acute rheumatism, cho- 
rea, and heart disease are coming to be regarded as a 
quartet of one family. 

Whatever may be the useful functions of the tonsils, 
including the third tonsil, when in a state of health, 
there can be no question that after they become dis- 
eased, they are of no use and are often positively harm- 
ful to the body. 

Diseased tonsils are often associated with defects of 
the nose. The explanation is simple when we consider 
that the nasal and throat passages are continuous, and 
that their anatomical structure is very similar. The 
throat, nose, eustachian tube, and middle ear are lined 
by one and the same membrane. Disease of any part of 
this membrane tends to spread to all of it. The inti- 
mate structural relations of these parts are shown in 
Fig. 16. 

Tonsils may be enlarged without any apparent 
inflammation, and, as already explained, this condi- 



THE NOSE AND THROAT 205 

tion is not always to be regarded as especially serious. 
Whether overgrown tonsils should or should not be 
removed will depend (a) upon the degree of enlarge- 
ment, and (6) upon the cause of enlargement. In most 
cases only a physician of experience can render an 
intelligent judgment. Simple enlargement may be 
only a part of a general lymphatic disturbance, and 
may in some cases have existed from birth. If the ton- 
sils are so large as to interfere with breathing, they 
should certainly be removed. One frequently sees ton- 
sils of this character so large as to meet in the middle 
line of the throat. 

Tonsils may be enlarged because of acute o^ chronic 
infection causing inflammation. In every case of 
acute tonsillitis there is some such enlargement, which, 
however, may not require any surgical treatment. On 
the other hand, small tonsils are often diseased and 
capable of producing acute tonsillitis. In such in- 
stances they practically always require removal. 

Tonsils which are chronically enlarged because of 
inflammation should always be removed. Such tonsils 
often have crypts, or holes, containing cheesy material, 
and tonsils of this character are not only offensive but 
constantly septic. The products of inflammation fill 
the crypts, and poisonous materials are continually 
being absorbed into the system. Cryptic tonsils, 
whether large or small, are rarely treated with any 
success by other means than total removal. In a word, 
tonsils which are so large as to form an obstruction to 
breathing, and those chronically inflamed, whether 



206 THE HYGIENE OF THE SCHOOL CHILD 

large or small, should be completely removed. Succes- 
sive attacks of tonsillitis from any cause usually indi- 
cate the necessity of surgical interference. 

Ordinarily this can be properly done only by a nose 
and throat specialist. Many operations on tonsils are 
done by unskillful operators with results which are 
disappointing. If the tonsils are not completely re- 
moved they are likely in time to become enlarged 
again. Tonsils completely removed do not return. 
Much of the irregularity seen in tonsils is due to 
shrinkage following chronic inflammation or incom- 
plete removal. 

The proportion of school children who suffer from 
enlarged or otherwise diseased tonsils is fairly constant. 
There are some local differences, but the average is 
about the same for the whole school population. Dr. 
Hoag has found that in California, for some unexplain- 
able reason, the proportion of diseased tonsils is con- 
siderably larger than in Minnesota. In general it is 
safe to say that about one eighth of our school chil- 
dren suffer from this defect. The proportion is consid- 
erably larger for children under ten years of age than it 
is for those older, and for children of the poor than for 
those of the more fortunate classes. 

The effects of diseased tonsils are well classified by 
Cornell as follows : — 

(1) Obstruction of respiration (usually not great) ; 

(2) Increased liability to throat infections; 

(3) Increased liability to heart infections and chorea; 

(4) Increased liability to tuberculosis ;j 



THE NOSE AND THROAT 207 

(5) Inflammation of the cervical glands; 

(6) Lowered general vitality; 

(7) Ear involvement. 

No child with chronically diseased tonsils can possi- 
bly be well. Furthermore, he is constantly in danger 
of attacks of tonsillitis, diphtheria, scarlet fever, or 
rheumatism, and he is rendered abnormally suscept- 
ible to tuberculosis. His general vitality is almost 
always lowered and his mental processes may be re- 
tarded. No one should ever hesitate about the ques- 
tion of removing diseased tonsils from the throats of 
children. The operation is safe in the hands of a skill- 
ful physician, and enormously increases tie child's 
possibilities of health, happiness, and eflficiency. 

Adenoids 

Adenoids, as already stated, consist of lymphoid 
tissue forming a third tonsil and are situated behind 
the soft palate in what is called the naso-pharynx. It is 
a perfectly normal structure until it becomes over- 
grown or infected.^ Adenoids more or less completely 
close the passage between the nose and throat and in 
this way produce the condition known as ** mouth- 
breathing." 

The adenoid child breathes with the mouth open 
because it is impossible for him to breathe in any other 
way. He usually sleeps with his mouth open and com- 
monly snores. The obstruction from which he suffers 
is rendered much worse by taking cold, for the reason 

^ Most overgrown adenoids are infected. 




208 THE HYGIENE OF THE SCHOOL CflILD 

that adenoids consist of a soft spongy mass of tissue 
which is always congested (full of blood), and which 

becomes much more 

congested when the 

child has a cold. 

Adenoids are some- 

^ADENOIDS times found in infants 

at birth or soon after, 

but are more likely to 

FIG. 15 be observed between 

A passage blocked by adenoids , 

the ages oi 3 and 10 
years. After puberty (12 to 16 years) they tend to 
disappear and are seldom found in adults; but in those 
cases in which they have been allowed to " absorb " 
without surgical treatment, unfortunate results always 
persist as evidence of the neglect. 

There are three reasons for the greater frequency 
of adenoids in the early years of school life. (1) The 
lymphatic functions play a much larger part in the 
child than in the adult, and the lymphatic are there- 
fore more prone to overgrowth. (2) As adolescence 
approaches, the throat enlarges very rapidly, and mark- 
edly relieves the crowded condition. At the same time 
the adenoids themselves are reduced in size by shrink- 
ing and partial "absorption." (3) Many of the older 
children have had their nose and throat obstructions 
surgically removed. 

The proportion affected does not seem to vary greatly 
in the different countries of Europe and America. 
Kafemann reports 7.8 per cent for boys and 10.6 per 



THE NOSE AND THROAT 



209 



cent for girls. Laaser (9) estimates that 10 per cent of 
the children in the common schools of Germany have 
adenoids. Of 9031 children examined in Leipzig, 23.2 
per cent were affected. The number reported by the 
medical examiners in Stockholm was 13.8 per cent in 
1905, and 12 per cent in 1906. Another Swedish inves- 
tigation, by Stangeberg, reports 16 per cent. 

Yearsley, however, on the basis of an especially care- 
ful study of 2315 children, estimates that 37 per cent 
of the pupils in the 
elementary schools of 
London have ade- 
noids (14). Years- 
ley's results show 
that of those who 
have adenoids, three 
fourths have also en- 
larged tonsils, and 
10.8 per cent ear 
complications. Sex 
differences, if any 
exist, are not great. 

The experience of 
Dr. Hoag, involving 
observations of more 
than 75,000 school children in widely different parts 
of the country, justifies placing the number at 8 per 
cent. More careful examination than is possible in 
routine school work would probably demonstrate a 
still larger proportion of adenoid children. In general. 




UPPER 
TOOTH 

LOWER 
TOOTH 



FIG. 16 
A clear passage to the lungs, 
arrows.) 



(Follow the 



210 THE HYGIENE OF THE SCHOOL CHILD 

adenoids occur somewhat more frequently among poor 
and neglected children than among children of the 
better classes. This, however, is equally true of nearly 
all kinds of common physical defects. 

Effect of adenoids 

Retardation statistics show that defects of breath- 
ing are decidedly more common among retarded chil- 
dren than among those who are up to grade. Comparing 
the physical conditions of 1093 promoted children with 
those of 303 who failed of promotion, Superintendent 
Verplanck, of South Manchester, Connecticut, found 
adenoids one third more frequent in the latter group 
than in the former. In a study of 449 retarded chil- 
dren in the first grade in Elmira, New York, it was 
found that of those who had been in this grade two 
years 19 per cent were afflicted with adenoids; of those 
who had remained in the grade four years or more, 50 
per cent. Statistics by Leonard P. Ayres, collected for 
the purpose of ascertaining the relation between physi- 
cal defects and school progress, showed that obstructed 
breathing was 66 1 per cent more frequent among the 
dull than among the bright, the proportion among the 
bright, average, and dull being 9, 11, and 15 per cent, 
respectively. Compared with children having no de- 
fect, adenoid children showed a loss of 14 per cent in 
rate of school progress. Children with hypertrophied 
tonsils showed a loss of 9 per cent.^ 

^ These figures are based upon the data presented in chapter xi of 
Guliek and Ayres's Medical Inspection of Schools, 1913 edition. 



THE NOSE AND THROAT 211 

, Bonazzola (quoted in 5, p. 60), in an examination of 
400 school children, found 141 who displayed symp- 
toms of aprosexia. Examination of the 141 showed 
adenoids in all but 24 and some other form of nasal 
obstruction in all of the latter. Wilbert found, in a 
school composed of 375 boys, 26 who were described as 
bad scholars, and of these, 22 had adenoids. 

If we can assume that 10 per cent of all our school 
children suffer from obstructed breathing, and if we 
can further assume that their instruction at school is 
only 90 per cent effective because of the dullness and 
ill-health produced by this defect, then the money loss 
from this source alone amounts to at least four million 
dollars annually. However, the financial aspect of the 
problem is much less important than the pedagogical, 
moral, and humanitarian considerations involved. 

The teacher should nevertheless bear in mind that 
adenoids and enlarged tonsils are not responsible for 
all the dullness found among school children. While 
marked mental improvement often follows the surgical 
removal of nasal obstructions, it is vain to hope that 
stupidity can, be universally eliminated by so simple a 
measure. The badly retarded child is usually mentally 
and physically subnormal by endowment, and often 
his physical defectiveness is only a symptom of the 
subnormality, not its true cause. There is danger that 
the influence of physical defects in causing retardation 
will be overemphasized : it is so much easier to remove 
adenoids than it is to ascertain the actual causes of 
retardation; so much easier to rely on surgery for its 



212 THE HYGIENE OF THE SCHOOL CHILD 

cure than to devise the needed reforms of educational 
administration and pedagogical procedure. 

By questioning teachers, Cornell (2) investigated 
the mental effects of adenoid removal in the case of 63 
children. Of these, 19 were said to have "improved 
much," 25 to have "improved," 16 to have remained 
unchanged, and 3 to have deteriorated. The records of 
subsequent promotions attained by these pupils were 
distinctly less favorable. Out of 97 opportunities for 
promotions in the months following the operations 
there were 61 failures. 

Yearsley's valuable study of London children (14) 
shows that only in severe cases are adenoids accom- 
panied by the so-called "adenoid face" or by extreme 
aprosexia (inability to attend). Yearsley defends the 
view, now growing in favor, that adenoids are not the 
sole cause of the abnormally high palate so commonly 
associated with them, but that the arched palate is to 
some extent the cause of the adenoids; likewise that 
the associated irregularity of the teeth is partly due to 
the abnormal palate and not merely to the presence of 
adenoids. At any rate, adenoids and arched, narrow 
palates are usually found together. Dr. N. H. Bul- 
lock's measurements of 300 adenoid and 300 normal 
children of the same age showed that the breadth of 
upper jaw in the adenoid children averaged .6 cm. 
below that of normal children. 

Ajs shown in chapter xi, mouth-breathing and irreg- 
ularities of the teeth predispose to dental caries. 

Such mental effects as are produced by obstructed 




THE PRIMARY INCISION FOR SEPARATING THE HYPERTROPHIED 

TONSIL FROM ITS ATTACHMENTS 

From Phillips's Disenxes of the Ear, Nose and Throat. By permission of The 

F. A. Davis Company, Philadelphia 







BEFORE AND AFTER REMOVAL OF ADENOIDS 



THE NOSE AND THROAT 213 

breathing have not been satisfactorily accounted for. 
One theory is that adenoids, particularly, interfere 
with the nutrition of the brain and with the removal of 
its waste products. This was the explanation offered by 
Guye, of Amsterdam, who first described the mental 
symptoms. It is more commonly believed that the 
aprosexia is due chiefly to chronic toxaemia (general 
poisoning) produced by the diseased lymphoid tissue, 
but in part, also, to the reduced depth of respiration 
and to lowered physical activity. Consideration of the 
hygienic functions of the nose would lead us to expect a 
gradual reduction of vitality when these functions can- 
not be performed. % 

Whatever may be the correct explanation for the 
frequent association of adenoids with certain physical 
and mental defects, it is well known that the adenoid 
child seldom develops normally. He is usually less 
active and less inclined to play. Kaster and Malherbe ^ 
found from measurements of 36 cases that growth in 
height, weight, and chest girth was, on the average, 
three times as rapid in the month immediately follow- 
ing the operation as in the month preceding, 
t Lung capacity and the shape of the thorax are nearly 
always affected by obstructed breathing. We are in- 
debted to Dr. N. H. Bullock, medical examiner for the 
schools of San Jose, California, for valuable data on 
this point. Dr. Bullock compared the front-to-front 
and side-to-side diameters of the chests of 300 ade- 
noid children with those of 300 normal children of the 
* Quoted by Burnham. 



214 THE HYGIENE OF THE SCHOOL CHILD 

same age. Of each group 200 were 14 years of age; 
the remaining 100 of each group, 7 years of age. In the 
case of the 14-year-olds, the side-to-side diameter of 
the chest averaged ij inches below normal in the 
adenoid children, and the front-to-back diameter 
about 1 inch above normal. This gives the so-called 
"pigeon-breast" ("barrel-chest," "funnel-chest," etc.) 
so commonly found with adenoid children. In the case 
of the 7-year-olds, the breadth of chest averaged about 
one third inch below normal, and the depth of chest 
about one half inch above normal. Of the adenoid 
children, 6 per cent at 6 years and 16 per cent at 14 
years had the "pigeon-breast," and practically all of 
the remainder a greater or less degree of " barrel-chest " 
or "funnel-chest." Among the non-adenoid children 
there was not a single marked case of these deformities. 
A comparison of the 6-year-old and the 14-year-old 
adenoid children shows that the deformity of thorax is 
much worse in the latter. The adenoids have had more 
time to do their injury. 

As already stated, if the nasal passages are healthy 
throughout, the air which is breathed is rendered 
sterile before it reaches the lungs. This is true even 
when the number of organisms inhaled runs up into 
the thousands per hour. But if adenoids are present, 
a catarrhal inflammation takes place in the mucous 
linings of the nose. Three things result from this con- 
dition, all of them a menace to health : — 

(1) The air is not properly humidified in its passage 
to the lungs; 



THE NOSE AND THROAT 215 

(2) it is not sufficiently warmed before reaching the 
lungs; and 

(3) it is imperfectly filtered of injurious bacteria. 
Adenoids are also frequently the seat of tubercular 

infection. Pilet found 1 case tuberculous in 10; Brie- 
ger, 5 in 78; Goltstein, 3 in 33; Brindel, 8 in 64; Lewin, 
10 in 200; Rethi, 6 in 100; Poliakov, 4 in 50, etc. (5, p. 
66). Peters found tuberculosis in 45 per cent of 905 
adenoids. 

It is not necessary to exaggerate the evils of ade- 
noids in order to place proper emphasis on the hygiene 
of nose and throat. There is no common type of defec- 
tiveness more serious as regards ultimate consequences 
for health than diseased conditions of the upper respir- 
atory passages. The ultimate injury far exceeds the 
immediate. A given adenoid child may be able to keep 
out of the sick-bed and to make a fairly creditable 
showing in school, but may nevertheless fail on account 
of this defect to develop normal vitality. Many years 
after the close of school life, such a child is likely to 
prove an easy prey for infectious diseases and may pay 
the penalty of neglect by a premature death. 

Causes of adenoids 

Many explanations have been given to account for 
the presence of adenoids, no one of which is altogether 
satisfactory. Among the most common explanations 
are the following: — 

(1) The "lymphatic constitution" (supposedly he- 
reditary). 



216 THE HYGIENE OF THE SCHOOL CHILD . 

(2) Poor nutrition, and especially rickets and latent 
tuberculosis. 

(3) Thumb-sucking and the use of the "pacifier." 

(4) General unhygienic conditions of life, such as 
injurious dust, excessively dry and overheated atmos- 
phere, etc. 

(5) Infectious diseases of childhood, especially neg- 
lect of colds, whooping-cough, etc. 

(6) Deviation of the septum (partition between the 
nostrils) or the presence of other partial obstructions to 
nasal breathing. 

The preventability of adenoids and diseased tonsils 
is a question which has received less consideration 
than it deserves. The fact that all of the causative fac- 
tors above enumerated, except the first, are largely 
subject to control, suggests that appropriate preven- 
tive measures might accomplish a great deal. Even 
the heredity factor may be eliminated by the practice 
of eugenics, once the laws of transmission are better 
understood. 

Suggestions for observation 

The signs and symptoms of adenoids maybe grouped 
as follows: — 

Nasal voice and defects of articulation; 
Mouth-breathing ; 
Catarrh of nose or throat; 
Pronounced tendency to colds; 
A heavy or stupid expression; 
An unusual fullness of the eyes; 
Slow mentality (often retardation) ; 



THE NOSE AND THROAT 217 

Poor physical development (often deficiency in play life) ; 
Earache; 
Ear-discharge; 

Deafness, or partial deafness; 
Crooked or prominent upper teeth; 
A high, arched roof of the mouth; 
Snoring; 
Disturbed sleep; 
Loud breathing during the day; 
Undeveloped facial bones; 

Nervous instability, shown by peevishness, finical habits, 
etc. 

Some but not all the indications just enumerated 
will always be found present with adenoids. The signs 
most important for teachers and parents to note are 
the following: — 

Open mouth and snoring at night (often with restlessness) ; 

Nasal, expressionless vjoice; 

Mouth-breathing during the day; 

Heavy facial expression; 

Mental dullness or apathy; 

High, arched palate; 

Crooked, prominent upper teeth. 

Other throat symptoms may be listed as follows: — 

Complaints of sore- throat; 

Frequent attacks of tonsillitis; 

Thick voice; 

Offensive breath; 

Rheumatism (often associated with diseased tonsils). 

Summary 

(1) The germs of many serious infectious diseases 
make their way into the body by way of the nose and 



218 THE HYGIENE OF THE SCHOOL CHILD _ 

throat. If the tissues of these passages are unhealthy 
the resistance to such diseases is reduced. 

(2) Obstructions of the nose, causing mouth-breath- 
ing, interfere with the important processes of filtering, 
warming, and humidification of the inspired air in its 
passage to the lungs. 

(3) A healthy nose and throat are necessary for 
normal speech and for effective instruction in modern 
language. 

? (4) Defects of nose and throat are responsible for 
a large majority of the cases of deafness and partial 
deafness. 

(5) Chronic inability to breathe through the nose 
sometimes results in mental torpor, defective growth, 
dental caries, and general low vitality. The influence 
of adenoids in causing f eeble-mindedness, however, has 
probably been exaggerated. 

(6) The mechanism by which adenoids and en- 
larged tonsils produce their injurious effects is not 
suflficiently known. 

(7) Tonsils which are badly enlarged, or which are 
subject to frequent inflammation (tonsillitis), nearly 
always require removal. 

(8) Adenoids which are large enough to interfere in 
any degree with nasal breathing, or which show any 
tendency to cause inflammation of the eustachian tube 
or the middle ear, should always be removed. 

(9) Removal should take place early, usually by 
the sixth year, and sometimes much earlier. 

• (10) The preventability of adenoids and diseased 



THE NOSE AND THROAT 219 

tonsils is a question which has not been sufficiently 
investigated. 

(11) Teachers should be thoroughly familiar with the 
common symptoms of nose and throat disorders and 
with their results. They should instruct children from 
the earliest grades in the importance of unobstructed 
nasal breathing. 

(12) The number of school children in the United 
States suffering from obstructed breathing is at least 
two million. The educational and hygienic treatment 
of these unfortunates is a matter of great national 
concern. 

REFERENCES % 

♦1. W. H. Burnham: "The Hygiene of the Nose." Fed. Sem., 1908, 

pp. 155-69. 
*2. W. S. Cornell : Health' and Medical Inspection of School Children. 

1912, pp. 244-89. 

3. E. A. Crockett: "Diseases of Nose and Throat of Interest to 
Teachers." Proc. N.E.A., 1903, pp. 1028-31. 

4. E. Erdely: "Sind die adenoiden "Wucherungen angeboren?" 
Jahrb.f. Kinderheilkunde, 1911, pp. 611-29. 

5. C. A. Dighton: A Manual of Diseases of the N aso- Pharynx ; 
With Special Reference to the Part played by them in Diseases 
of the Ear. London, 1912, pp. 168. 

6. H. Gutzmann: "Ueber Horen u. Verstehen," Zt. f. Ange. 
Psych, u. psyc. Sammelforschung, 1908, pp. 483-503. 

7. H. Hagelin: "Adenoids and Modern Language Instruction." 
Mod. Lang. Teaching, vol. iv, pp. 16-19 and 38-44. 

*8. R. Kafemann: "Ueber d. Beinflussung geistiger Leistungen 

durch Behinderung der Nasenatmung." Psych. Arbeiten, 1904, 

pp. 435-53. 

9. M. Laaser: "Einige Schulhygienische Betrachtungen." Zt. f. 

Schulges., 1898, pp. 365-72. 

*10, Dr. Mouton : " Die Aprosechsia Nasalis dei Schulkindern." Zt. f. 

Schulges., 1903, pp. 71-80. 
*11. H. J. Mulford: "The Throat of the Child." Ed.Rev^ASm,^^. 
261-72. 

12. P\ J. Poynton: "The Prevention of Rheumatism in Childhood." 
School Hygiene, 1912, pp. 131-42. 

13. G. E. Schweinitz and A. B. Randall: An American Textbook of 
Diseases, of the Eye, Ear, Nose, and Throat. 1906, parts 3 and 4. 



220 THE HYGIENE OF THE SCHOOL CHILD 

(See especially articles by Freeman, Bryan, Asch, Wright, 
Newcomb, and Leland.) 
*14. Macleod Yearsley : "Occurrence of Adenoids in London County 
Council Schools." Journal of Children's Diseases, February 
and March, 1910. 

See also standard texts on school hygiene, medical inspection of 
schools, and children's diseases. ^ 



CHAPTER XIII 

DEFECTS OF HEARING AND THE HYGIENE OF THE EAR 
Written with the assistance of Dr. E. B. Hoag 

The prevalence of defective hearing 

Studies of defective hearing among school children 
have given extremely large differences as regards the 
proportion affected. Some investigators report as few 
as 1 per cent; others as many as 50 per cent. This wide 
range in the statistics does not indicate anj^ corres- 
ponding range in the actual prevalence of the defect, 
but is due mainly to the lack of a uniform standard as 
to what constitutes "defective hearing" and to lack of 
uniformity in methods of testing. 
' It is only for sake of convenience that we are justi- 
fied in rigidly classifying individuals as having either 
"defective hearing" or "normal hearing." The most 
careful tests show that there is no plain demarcation 
between the two classes. Normal hearing is simply 
that degree of auditory acuity found in the majority 
of individuals. This shades off gradually into subnor- 
mal hearing on the one hand, and into superior hearing 
on the other. The farther we get away from the aver- 
age in either direction, the smaller the number of cases 
represented. Because of the influence of disease, the 
number of cases with defective hearing is much greater 
than the number with above-normal hearing. 



THE HYGIENE OF THE SCHOOL CHILD 

With the above explanation, such differences as 
appear in the following statistics ought not to be mis- 
leading. A low figure means that only severe degrees 
of the defect have been reported; a high figure means 
that minor defects also have entered into the results. 





TAE 


5LE 25 










Per cent 


Investigator 


Place 


No. of Children 


reported 
defective 


Reichard 


Riga 


1055 


22.27 


Weil 


Stuttgart 


5905 


31.22 


Gelle 


Paris 


1400 


20 to 25 


Moure 


Bordeaux 


3588 


17.15 


Bezold 


Munich 


1918 


25.8 


Zhermunsky 


St. Petersburg 


3577 


13 to 16 


Cheattle 


London 


1000 


50 


Felix 


France 


1038 


31 


Laubi 


Switzerland 


2200 


10.6 


Smedley 


Chicago 


5760 


23. 


Newmayer 


Philadelphia 


( 3587 "exempt" 
1 1418 "non-exempt" 


1. I 

2. i 


Bryan 


Camden, N. J. 


(8110 normal age 
( 2020 retards 


4. 
6. 


Medical 


New York City 


266,426 


.5 


examiners 








Medical 


Five East-End 


1006 


7.2 


examiners 


Schools of London 







The above results were secured by a great variety of 
methods and standards. The report covering the great- 
est number of children^ and one of the least valuable, 
is that from New York. In that city, evidently, a 
pupil has to be practically deaf in order to be con- 
sidered defective in hearing. Among the most careful 
tests yet made are those of McCallie in Philadelphia 
a,nd Reik in Baltimore. McCallie tested 560 ears 
and found 14 per cent "slightly deaf" and 2 per cent 



DEFECTS OF HEARING 223 

"quite deaf." Reik reports 10 per cent of 440 children 
as having defective hearing. 

We may safely conclude, therefore, that from 10 to 
20 per cent of school children do not hear normally and 
that the hearing of from 2 to 5 per cent is very seriously 
impaired. Sex and age differences are very slight, 
practically non-existent. 

The number of persons who are entirely deaf is 
usually given as about 700 per million. This would be 
about 60,000 in the United States. However, if the 
rate for Germany can be accepted for this country, our 
deaf must number not far from 75,000. About half of 
this is acquired; the rest hereditary. % 

The importance of normal hearing for mental 
development 

Hearing ranks in importance with vision as an 
avenue for the acquisition of knowledge. In certain 
respects, deafness is more damaging to mental devel- 
opment than blindness. Although the blind child, un- 
educated, may grow up very ignorant, he seldom gives 
the impression of being mentally defective. The un- 
educated deaf child, on the other hand, nearly always 
appears stupid. So true is this that deafness was for- 
merly believed to be always associated with disease or 
deficiency of the central nervous system. School chil- 
dren who hear poorly are always in danger of being 
mistaken by their teachers for dullards. 

This is readily understood when we stop to consider 
the role of hearing in everyday life. Deprived of this 



224 THE HYGIENE OF THE SCHOOL CHILD 

sense, even in part, the child suffers inevitable handi- 
caps. Language development is stunted because speech 
is imperfectly understood; and language is the main 
vehicle of mental progress. The earning power may 
be reduced 50 per cent. The social instincts may be 
starved or perverted because normal intercourse with 
other children is impossible. Partially deaf children 
are apt to be considered "queer." Deprived of the 
healthful and educative influence of cooperative play, 
such children often fail to develop normally either in 
body or character. Misunderstood and misjudged on 
every hand, they are likely to harbor silent resentment 
or to develop traits of irritability, stubbornness, and 
the like. 

That serious defects of hearing tend to produce 
school retardation has been fully demonstrated. The 
proportion of partially deaf children in the schools of 
Camden, New Jersey, was found to be 50 per cent 
greater among the retarded than among those who 
were up to grade. Newmayer's study of 5005 Phila- 
delphia children showed that the 3587 who were ex- 
cused from final examinations on the basis of good 
work had defects of hearing only half as frequently as 
the 1418 non-exempt. Barr asked Glasgow teachers 
to pick out 70 "very bright" and 70 "very dull" 
children. Examination of these revealed that 4 of the 
former and 10 of the latter were defective in both ears, 
while 10 of the former and 15 of the latter were defec- 
tive in one ear. Permewan had 203 pupils in Liverpool 
classified by their teachers as "bright," "average," or 



DEFECTS OF HEARING 225 

"dull/' and found that the average distance for hear- 
ing a watch tick was 51 feet, 47 feet, and 31 feet for the 
three classes respectively. Of 20 pupils reported as 
"poorest" in a school of Paris, Gelle found only 4 with 
normal hearing. Zhermunsky, at St. Petersburg, found 
24 per cent of the pupils with normal hearing were 
classed by their teachers as "poor" in school work, 
while the proportion of "poor" among those whose 
hearing was less than one third normal was 58 per cent. 
The percentage of partially deaf among 1000 London 
children was as follows : — 

Worst mentality 34i per cent 

Poor mentality 27 % 

Fair mentality 333 

Good mentality 31 

Excellent mentality 22 

The figures just quoted indicate that although par- 
tially deaf children are not always retarded, they are 
more likely to become so than children with normal 
hearing. Among the very dull, especially, the propor- 
tion of partially deaf is abnormally high. Likewise the 
proportion of retarded children among the very deaf is 
also extremely high. Thus Kobrak, testing 400 chil- 
dren of Breslau shortly after school entrance, discovered 
six whose hearing was less than one twentieth normal. 
Five of these were considered stupid by their teachers. 
Of 205 pupils of the Berlin Hilfsschulklassen (classes 
for the mentally defective), 20 per cent had less than 
one third normal hearing and 8 per cent less than one 
twentieth. Wanner found 12 out of 39 children in the 



226 THE HYGIENE OF THE SCHOOL CHILD 

Munich Hilf sschulklassen with less than one twentieth 
normal hearing (quoted by Kobrak). 

One reason for the correlation between deafness and 
retardation lies in the fact that a very large proportion 
of those with defective hearing are "adenoid children," 
and are for this reason mentally sluggish. But that the 
stupidity of the deaf is often apparent rather than real 
is shown by Kobrak's study of 677 children in the 
Hilfsschulklassen of Berlin. It was found that in these 
classes, where the pupils are given a large amount of 
individual attention and are instructed by teachers of 
special training, the partially deaf were making on an 
average better progress than those with normal hearing. 
The explanation is not that deafness is an advantage, 
but that many of these children in the classes for 
mentally defectives were there because they could not 
hear well and not because of defective mentality. 

The hearing of the deaf child is by no means uni- 
form, but varies according to the condition of the 
weather, the state of the throat, etc. On some days it 
is almost normal; at other times extremely poor. This 
results in what appears to be an unevenness of atten- 
tion and response; hence the child is likely to be scolded 
or otherwise unjustly treated. 

Another result of defective hearing is overstrain of 
attention and mental fatigue. In order to realize how 
serious this may be, one has only to recall the feelings 
of strain and exhaustion experienced after an hour or 
two spent in listening to a public speaker whose voice 
was hardly audible. 



DEFECTS OF HEARING 227 

Discharging ears 

The discharging ear presents a very serious condi- 
tion. If it is not treated until cured, the result is very 
likely to be either partial or total deafness. In many 
cases the infection spreads to the surrounding bone 
and necessitates a dangerous surgical operation. Some- 
times death results. To have chronic discharge of the 
ear is like living over a powder mine. The explosion 
may not come, but there is always a dangerous pos- 
sibility. Life-insurance companies reject applicants 
with chronic ear-discharge. Death from this cause 
often results in middle life, or after, and in such cas^ 
the condition usually dates back to childhoodk 

Severe defects of hearing are due to neglected inflam- 
mation of the middle ear of tener than to anything else. 
The condition is one which requires long-continued 
treatment. Skillfully treated, discharging ear is almost 
always curable; neglected, it remains indefinitely as a 
menace to the sense of hearing and to life itself. 

It needs to be clearly understood that the suppurat- 
ing middle ear is not primarily a disease of the ear, but 
(almost always) an infection which has spread from the 
nose or pharynx. The infection may also spread to the 
openings in the mastoid bone, which are in reality con- 
tinuations of the cavity of the middle ear, and there 
cause grave danger to life. It is to relieve this condi- 
tion that the *' mastoid operation" is performed. 

Medical inspection reveals that an average of some 
2 per cent of school children have ear-discharge, and 
the total number, counting those who have had the 



228 THE HYGIENE OF THE SCHOOL CHILD 

defect and recovered from it, amounts to 8 or 10 per 
cent. Denker found about 1 per cent of secondary- 
school pupils and 2 per cent of elementary pupils in 
Germany with present ear-discharge. The number who 
had had the defect at some time was approximately 12 
per cent (9). Of 1006 poor children in three average 
East-End Schools of London, 7.3 per cent had present 
ear-discharge and 13.4 per cent additional showed 
symptoms (cicatrices) of previous discharge. Dr. E. B. 
Hoag finds that from 2 to 3 per cent have chronic ear- 
suppuration. Cornell places the number at 1 to 2 per 
cent. The proportion is usually smaller with older 
children than with younger, due probably to the bet- 
ter habits of cleanliness among older children and 
to the fact that their adenoids and enlarged tonsils 
have often had the necessary surgical attention. The 
greater cleanliness of older children also doubtless con- 
ceals a good many cases of the defect. On the whole, 
Burnham's estimate of 2 percent does not seem exces- 
sive. This is not far from one case for each schoolroom, 
or a total of nearly a half -million in the schools of the 
United States. 

The causes of ear defects 

Apart from congenital deafness, which is nearly 
always due to heredity, defects of hearing have three 
main causes: (1) diseased conditions of the nose and 
throat; (2) infectious diseases; and (3) stoppage of the 
outer canal. 

The first-named cause is by far the most important. 



DEFECTS OF HEARING 229 

accounting for considerably more than half of all cases.^ 
The conditions of nose and throat most frequently- 
involved are adenoids, enlarged tonsils, and chronic 
catarrh. Most cases of acquired deafness in children 
are due, directly or indirectly, to diseased conditions of 
the nose or throat. Neglected colds, adenoids, chronic 
catarrhal conditions, and infectious diseases which 
affect the throat (measles, scarlet fever, and diph- 
theria) are the chief culprits. 

It will be remembered that the middle ear is con- 
nected with the pharynx by the eustachian tube, and 
that the mucous membrane of the middle ear is contin- 
uous with that of the eustachian tube and jiharynx. 
In childhood the eustachian tube is relatively short, 
wide, and straight, making an easy road over which 
disease germs may travel from the throat to the middle 
ear. Inflammation of the throat, such as is present in 
colds, catarrh, or disease of the tonsils, sometimes 
causes swelling of the walls of the eustachian tube and 
interferes with the ventilation and drainage of the 
middle ear. 

Normally, the mucus which is constantly being 
secreted by the membrane lining the middle ear is 
propelled through the eustachian tube by the wave 
action of the cilia. Disease of the mucous membrane, 
as in catarrh and the like, interferes with the action 
of the cilia and prevents drainage. When this occurs, 
two results are likely to follow: (1) the mucus of the 

* Holmes says 60 per cent; Zhermunsky, 64 per cent; Burkner, 
33 to 60 per cent; Cornell, 95 per cent; and Love, "nearly all." . 



230 THE HYGIENE OF THE SCHOOL CHILD 

middle ear (perhaps containing pathogenic bacteria) ac- 
cumulates for lack of normal drainage to the pharynx; 
and (£) the atmospheric pressure on the two sides of 
the eardrum becomes unequal and may cause a rupture. 
The accumulated pus then escapes through the outer 
canal and we have what is called the "suppurating 
ear." 

By early and thorough treatment of running ears 
many cases of deafness will be prevented. There is on 
an average about one case of ear-discharge in each 
schoolroom. The presence of cotton in the ear ought 
to excite the teacher's suspicion. Earache, although it 
may have other causes, is usually associated with acute 
inflammation of the middle ear. An aching ear is a 
signal of trouble; a discharging ear is a sign that the 
trouble has already occurred; a neglected discharging 
ear is a sign of progressive deafness. 

As already pointed out (chapter xii), defective 
hearing is one of the commonest symptoms of adenoids. 
Deaf children are therefore extremely likely to be 
mouth-breathers. Yearsley's report of 1006 children in 
London showed mouth-breathing one third more fre- 
quent among the partially deaf than among those with 
normal hearing. 

The next most common cause of defective hearing 
is acute infectious diseases, principally scarlet fever, 
measles, and diphtheria. These probably account for 
10 to 20 per cent of all cases. In measles and scarlet 
fever the middle ear is nearly always affected to greater 
or less degree. Of 500 totally deaf persons studied by 



DEFECTS OF HEARING 231 

Holmes, 36 cases were the result of measles. For years 
the writer has made it a practice in hygiene classes to 
ask the students how many know an individual who 
has defective hearing from this cause. There are few 
students who cannot name at least one such case. 
Children recovering from acute infectious diseases 
should be closely watched. Deafness, mastoid opera- 
tions, and the like are complications which should 
never be allowed to arise. 

It should also be emphasized that running ear fol- 
lowing an infectious disease is always a source of danger 
to others, as the discharge may contain the germs of 
the disease in question. Epidemics of scarlelJ^ fever, 
measles, and diphtheria are believed to originate some- 
times in this way. 

Accumulation of wax in the outer canal sometimes 
takes place, but this cause is responsible for only a 
small percentage of cases. The accumulation is some- 
times the result of a diseased condition of the outer 
canal causing profuse secretion and incomplete re- 
moval of the wax. Sometimes it is caused by pushing 
the wax against the eardrum in the effort to remove it 
with a pencil, hairpin, or damp cloth. Wax accumula- 
tions can be safely removed only by the physician. 

Contrary to popular opinion, accidents to the ear- 
drum do not ordinarily produce serious results unless 
the entire structure is destroyed. This is because the 
drum is endowed with such a remarkable growth power 
that the slight puncture, or rent, is quickly repaired. 
Complete recovery, in fact, may occur within a few 



232 THE HYGIENE OF THE SCHOOL CHILD 

hours. About 25 per cent of all adults have had a 
puncture of the eardrum. Even the total loss of the 
eardrum does not destroy hearing, though of course it 
greatly reduces it. One serious danger to the middle 
ear from loss of the eardrum is the increased danger of 
infection from without. In such cases there is nothing 
to block the entrance of disease germs. 
Summarizing, we may say : — 

(1) Deafness nearly always has its origin in child- 
hood. 

(2) In the vast majority of cases it is due to diseased 
conditions of the nose or throat, and is therefore usu- 
ally preventable. 

(3) The source of the trouble may be either (a) 
some chronic disorder of the throat, such as adenoids, 
enlarged tonsils, catarrh, etc., or (b) an acute infec- 
tious disease which involves the throat, usually scar- 
let fever, measles, or diphtheria. 

(4) Wax accumulations and injuries to the drum are 
occasional but not very frequent causes. 

The function of the school 

We have found that from 10 to 20 per cent of school 
children have defects of hearing. One fourth of these 
cases, at least, are very serious. A considerable num- 
ber are in danger of becoming entirely deaf; in other 
cases life itself is jeopardized. Instruction is rendered 
difficult, retardation may occur, and even the charac- 
ter of the child may be unfavorably influenced by the 
defect. ' 



DEFECTS OF HEARING 233 

It is well attested that nearly all cases of acquired 
deafness have their origin in childhood and that a large 
majority are preventable. Estimates of the proportion 
preventable range from 50 to 80 per cent. Theoreti- 
cally, at least, all the deafness due to acute infectious 
disease and to chronic nose and throat troubles (the 
two main causes) are preventable. 

It is evident, therefore, that if we would prevent 
deafness the children are the only rational point of at- 
tack. The question that remains is merely how best 
to reach them. 

There are only two institutions through which this 
may be done : the school and the home. If all j^arents 
were sufficiently intelligent to discover the defect, wise 
enough to appreciate its importance, and wealthy 
enough to secure the needed treatment, the function 
of the school would then be merely the negative one of 
avoiding injury to the child's ears. The facts, how- 
ever, are the reverse of this. Parents very rarely dis- 
cover the defect unless hearing is reduced as low as one 
third to one fourth the normal. They simply scold the 
child as listless or perverse. Other parents, aware of 
the defect, neglect it either from underestimation of 
its seriousness or from poverty. The school must 
undertake the work because it is the sole remaining 
agency. 

The school's first duty is to ascertain what children 
have imperfect hearing. The teacher cannot be de- 
pended upon to do this by mere observation any more 
than the parent. She, too, overlooks the defect and 



234 THE HYGIENE OF THE SCHOOL CHILD 

blames the child for inattention or regards him as 
stupid. Tests of hearing are necessary, and should be 
given to all the school children each year. The test 
given when the child enters school is especially import- 
ant. 

When defective hearing has been discovered, its 
cause should be ascertained. This can often be done 
by the regular school physician, but in very many 
cases an examination by a specialist is necessary. Ear, 
nose, and throat specialists should be employed by the 
school for this purpose. When this is not done, much 
follow-up work will generally be required in order to 
persuade parents to seek the right kind of medical 
advice. 

The next step is to secure the needed treatment. 
If adenoids are present, they should be removed. 
Enlarged tonsils and chronic catarrh should receive 
appropriate treatment. If the ear is discharging it must 
be cleansed and treated, usually for months. 

The present methods for dealing with the latter evil 
are utterly inadequate. As a rule, parents lack the 
knowledge of hygiene and medicine which would en- 
able them to appreciate the situation. Others, and 
these are very numerous, cannot afford the service of 
specialists at current rates and are reluctant to accept 
as a charity what they have not means to command. 
Even when a specialist is consulted, the tedious treat- 
ment which ensues (cleansing, syringing, etc.) is sel- 
dom carried out with the needed . regularity and care. 
Physicians find that in most cases it is simply folly to 



DEFECTS OF HEARING 235 

expect a cure by this method. The only assurance of 
success in this direction is for the child to be taken 
several times a week to the physician's office or to the 
hospital for the necessary treatment. Aside from the 
question of expense, it is useless to expect that this will 
be done. Treatment is almost sure to be intermittent 
and to be discontinued too early. Each visit to the 
hospital may consume hours of time. Whether rich or 
poor, we are too busy and impatient to submit to such 
a tedious ordeal. The result is that nine tenths of 
the cases of ear-discharge among school children have 
been and are still being neglected. 

The only solution of the problem lies in the ii^talla- 
tion of the school medical clinic for free treatment. 
This is England's solution, and it is the ideal one.^ The 
child goes as often as necessary to the near-by clinic, 
and receives the necessary treatment at the hands of a 
nurse or doctor. There is little waste of time, no loss of 
school attendance, and a mere bagatelle of expense. 
Even this is borne by the city. Best of all, the treat- 
ment brings cure. The only objection is the fetish of 
"parental responsibility." 

But theorize as we may about the danger of tamper- 
ing with parental responsibility, we are confronted by 
this fact of neglect. The rights of children to health 
and happiness surely outweigh any possible danger the 
scheme involves to the parents' sense of responsibility. 
It is not a very lofty system of ethics which would per- 

1 By 1913, ninety-five educational authorities in England had es- 
tablished clinics for the free use of school children. 



236 THE HYGIENE OF THE SCHOOL CHILD ^ 

mit children to become deaf as a moral lesson to their 
parents! 

Teachers and school nurses, as well as the medical 
inspector, should keep a sharp lookout for ear troubles. 
Children who return to school after an attack of 
measles, scarlet fever, or diphtheria need to be watched, 
and the first signs of earache or "thickness of hearing" 
should arouse suspicion. The same is true of children 
who are subject to chronic nose or throat trouble, who 
catch colds easily, etc. It is well for teachers to remem- 
ber that the child who has earache may be in danger of 
deafness. Follow-up work to secure the removal of ade- 
noids and the treatment of throat disorders cannot be 
too vigorously prosecuted. 

The school itself can accomplish something by pro- 
tecting the child from taking cold. Overheated and 
dusty schoolrooms, deprivation of physical activity, 
and the like predispose to just those conditions of nose 
and throat which give rise to so many cases of ear 
complication. 

Children should be taught how to care for the ear, 
how to wash it without risk of pushing the wax back 
against the drum, not to probe into it, not to box the 
ear, pull it, blow into it, etc. 

The teacher's voice should have sufficient force and 
carrying power to be heard without strain of attention 
in the rear of the room. Purity of tone and modula- 
tion, rather than loudness, are the essential qualities. 
The shrill voice is as objectionable for its poor acoustic 
properties as for its disagreeableness. Normal schools 



DEFECTS OF HEARING 237 

could well afford to substitute lessons in voice culture 
for some of their work in formal grammar. Classrooms 
should be built with proper proportions (not far from 
24 X 28 feet), and should be located where outside 
noises will not disturb. 

Directions for testing hearing 

The expensive apparatus and complicated proce- 
dures sometimes employed for testing auditory acuity 
are not in the least necessary for ordinary school pur- 
poses. With a little care any teacher can make a suffi- 
ciently accurate test of a child's hearing in from three 
to five minutes. Either the "watch" method%or the 
"whisper" method may be used. Each has its advan- 
tages and disadvantages, but on the whole the latter is 
perhaps somewhat more satisfactory. 

For the whisper test a room at least twenty-five or 
thirty feet long is necessary. At this distance a rather 
low whisper is easily audible to persons of normal hear- 
ing. The pupils should be tested singly. The child to 
be tested should be placed in a chair at one end of the 
room with one ear toward the teacher. The other ear 
must be closed tightly with a rubber stopper or with 
clean cotton. If a stopper is used, it should either be 
disinfected for each child or replaced by a new one. If 
cotton is used, it should be rolled into a rather firm 
ball so that in removal remnants will not be detached 
and left in the canal. 

The examiner should stand at the other end of the 
room and pronounce in a whisper of uniform loudness a 



238 THE HYGIENE OF THE SCHOOL CHILD 

list of words. Numerals chosen at random from 1 to 
100 are suitable. The distance of the examiner should 
remain the same throughout the test, the acuity of 
hearing being represented by the percentage of whis- 
pers heard. If a majority of the children of a class can 
hear, for example, 10 out of a list of 20 whispered 
numerals, then 10 out of 20 is taken as the standard for 
normality. The ear that hears only 5 is accordingly 
recorded as half normal, etc. 

This is known as the "method of constant range," as 
contrasted with "the method of extreme range." By 
the latter method, the examiner moves from a distance 
at which the sound is clearly heard to a point where it 
is no longer audible. The distance at which the sound 
entirely ceases to be heard is recorded, and the reverse 
procedure is then followed out. That is, the examiner 
begins at a point where the sound cannot be heard at 
all and moves closer until it is unmistakably perceived. 
The average of the two records thus secured represents 
the child's hearing range for this particular stimulus. 

The method first described is preferable because 
it is less likely than the other to be vitiated by the 
reflection of sound from the walls. It does not, how- 
ever, enable us to measure the hearing of children who 
are extremely deaf. 

Whatever the method, and whether watch or whis- 
per be employed, the standard is purely a relative one. 
Different watches, likewise the whispers of different 
people, vary much in loudness. Rooms also differ in 
acoustic properties. The teacher should take as her 



DEFECTS OF HEARING 239 

standard of normality the average performance of a 
majority of children of a class. Those who fall far 
below this are certainly not normal, and ought to be 
examined by the school doctor or by an aurist. 

The tests should be given to all the children, not 
simply to those whose hearing is under suspicion. 
Children who are partly deaf become wonderfully 
adept at lip reading, guessing at meanings when only 
fragments of speech are heard, parrying questions, 
and the like, so that a high degree of the defect may 
exist without exciting suspicion in any but a close 
observer. It is not meant that the child consciously 
makes false pretenses of hearing. It is all siAply an 
unconscious adaptation to a condition whose presence 
the child himself is ordinarily not aware of. The semi- 
deaf child is not conscious of his defect because he has 
no other standard of hearing than his own. 

Special schools for deaf children 

We must recognize the right of all children to a free 
education who are able to profit by it. This includes 
children of all degrees of deafness. The education, 
moreover, should be just that kind from which the 
child in question will derive the greatest benefit. 

The education of deaf-mutes is usually provided for 
in state institutions, but thus far little provision has 
been made for the large number of children who are 
not entirely deaf, but who are yet too deaf to derive 
the maximum profit from the ordinary class. 

As Dr. Love and Dr. Yearsley, two noted English 



240 THE HYGIENE OF THE SCHOOL CHILD 

authorities on this question, have urged for many- 
years, the most imperative need in this field at present 
is for a more scientific classification of deaf children 
for educational purposes. According to Dr. Love, who 
has examined institutions for the deaf in all parts of 
Europe and America, a large proportion of those who 
are being educated in these institutions do not right- 
fully belong in schools for deaf-mutes. They are the 
children who have a considerable remnant of hearing 
or who became deaf several years after they had learned 
normal speech. 

On the other hand, there are many children in the 
regular classes of the public schools who are entirely 
too deaf to be properly taught with normal children. 
This group probably includes somewhat more than 1 
per cent of the entire school enrollment. Stewart,^ on 
the basis of 12,200 children examined, places it at 1.16 
per cent. Jones, in an investigation of 3300 children 
for the London County Council, reports 1.5 per cent. 
For this type of children special classes in the public 
schools are an absolute necessity. They should not be 
educated with deaf-mutes because they need the com- 
panionship of normal children. Berlin has had such a 
class since 1907 and London since 1910. The number of 
children who belong in such classes is at least ten times 
as great as the total number of deaf-mutes. 

Deaf-mutes may also be taught in still other special 
classes of the day school, but the residential school has 
certain advantages. If the child's home environment is 
* Quoted by Love. 



DEFECTS OF HEARING 241 

good, the special day school is perhaps better, for the 
reason that companionship with normal people favors 
healthy social development. London has 500 deaf- 
mutes in special day classes of the public schools. 

In whatever type of schools deaf-mutes are educated, 
we are not to suppose that all of them require exactly 
the same kind of training. Normal children themselves 
do not; and precisely because the deaf-mute is a deaf- 
mute and the difficulties of his education therefore 
multiplied a hundred fold, it is so much the more 
important that we base our methods on medical and 
psychological study of the individual child. We refer 
here especially to the choice between the twomiethods 
in vogue for the instruction of the deaf ; the oral and 
the manual. 

For a half-century the champions of these two 
methods have waged bitter warfare. It is now pretty 
well agreed that a majority of deaf-mutes can learn 
the oral method and that they need to do so. The 
question is chiefly whether this method should be made 
universal. It is so, practically, in Germany. But it is 
well attested that a considerable proportion of deaf- 
mutes succeed indifferently or fail altogether by the 
oral method. According to Love, some 15 per cent of 
deaf-mutes are mentally defective, and with these, the 
oral method is never very successful. Others, also, 
succeed badly with it. It is absurd to universalize a 
method merely because it works well in a majority of 
cases. 

The rule should be, educate the deaf child in the 



242 _THE HYGIENE OF THE SCHOOL CHILD . 

highest type of school for which he is fitted. What this 
may be in any particular case can only be determined 
by a study of the individual child. 

As Love points out, the deaf and the semi-deaf 
should have the advantages of a longer training than 
normal children. The school should get them earlier 
and keep them later. The school period could well 
extend from 3 to 17 years. The ideal pedagogy for the 
special classes here advocated remains to be worked 
out. If the education of deaf and semi -deaf children is 
ever to be placed on a sound basis, opportunities will 
have to be provided for the scientific training of those 
who teach them. 

Children who are only slightly deaf can be taught in 
the same class with normal children, but they should 
be given an advantage in seating. This is a precaution 
which no teacher can ignore without grave injustice 
to the child concerned. In the average group of forty 
or fifty children from one to three will almost certainly 
be found in this group. 

Mention should also be made of psychic deafness, 
i.e., defective ability to interpret sounds (usually speech 
sounds), without any defect of the vocal organs them- 
selves. Slight degrees of psychic deafness are by no 
means rare, and the defect is usually one which re- 
sponds in a remarkable way to special training. Some- 
times it is mistaken for true deafness, especially in 
children whose associations have been mainly with 
deaf-mutes. The writer has found one such case, of 
mild degree, in the seven-year-old son of deaf-mutes. 



DEFECTS OF HEARING 243 

This child, whose ears and mentality were both nor- 
mal, was thought by his teachers to be both mentally 
defective and very hard-of-hearing. 

Some indications of ear defects 

Pupil often says "What? " 
Inattention; 
Stupid appearance; 
Expressionless voice; 
Poor spelling; , 

Poor progress in general; 
Imperfect speech; 
Complaint of earache; 

Running ear (discharge often present without bemg eas- 
ily observed). 

Peculiar postures (in attempt to hear). 

Difficult nasal breathing (often present with ear trouble). 

REFERENCES 

; 1. Gustav Alexander: "Die Schularztliche Ohrenuntersuchung 

an der Volksschule zu Berndorf 1910-1912." Zt. f. Schulges., 

1912, pp. 713-22. 
2. Fr. Bezold: Schuluntersuchungen uher das Kindliche Hororgan. 

1885. (Reviewed by Chrisman.) 
*3. Clarence J. Blake: "The Importance of Hearing-Tests in Public 

Schools." Proc. N.E.A., 1903, pp. 1013-19. 
4. Frank G. Bruner : "The Hearing of Primitive Peoples." Colum- 
bia Univ. Contrib. to Phil, and Psych., vol. xvii, no. 3. 
*5. K. Braukmann: "Ueber die Bedeutung des Gehors u. die Geis- 

tigen Folgen seiner Storungen im kindlichen Lebensalter." Zt. 

f. Schulges., 1898, pp. 129-39. 
*6. W. H. Burnham: "The Hygiene of the Ear." In Monroe's 

Encyclopedia of Education, 1912, vol. ii. 
*7. Oscar Chrisman: "The Hearing of Children." Ped. Sem., vol. Ii, 

1892, pp. 397-441. 
*8. W. S. Cornell: The Health and Medical Supervision of School 

Children: 1912, pp. 290-304. 
*9. Alfred Denker: "Ueber die Horfahigkeit u. d. Haufigkeit 
, des Vorkommens von Infectionskrankheiten im kindlichen u. 



244 THE HYGIENE OF THE SCHOOL CHILD 

jugendlichen Alter." First International Congress for School 
Hygiene, 1904, vol. iii, pp. 230-41. 
10. K. V. Hercsuth : " Intellectual and Moral Development of Deaf- 
Mutes." Eos, April, 1911. 

*11. Kobrak: "Beziehung zwischen Schwachsinn u. schwerhorig- 
keit." Zt.f. Schulges., 1908, pp. 87-97. 
12. LudwigKotelmann: (ScAoo/^2/5'iene, 1899, chap. X. (Translated 
by Bergstrom and Conradi.) 

*13. James Kerr Love: The Deaf Child. London, 1911, pp. 192. 

*14. James Kerr Love: "The Educational Treatment of the Deaf in 
all Stages from Impaired Hearing to the Totally Deaf." Second 
International Congress for School Hygiene, 1907, pp. 828-39. 
15. D. P. MacMillan: "Some Results of Hearing-Tests of Chicago 
School Children." Proc. N.E.A., 1901, pp. 876-80. 

*16. W. H. Pyle: Personal Hygiene. 1910. (Chapter by B. A. Ran- 
dall, "The Hygiene of the Ear," pp. 139-68.) 

17. F. H. Quix: "Die Prophylaxe der Taubheit bei Schulkindern." 
Inter. Mag. School Hygiene, vol. vi, 1910, pp. 422-30. 

18. Dr. Reinf elder : "Schwerhorigkeit u. Hdrschule." Die Jugend- 
fursorge, 1909, Heft 3. 

19. Randall and De Schweinnitz: American Textbook of the Dis- 
eases of Eye, Ear, Nose, and Throat. (Especially articles by 
Holmes, Buck, Wurdemann, Miller, etc.) 

*20. Macleod Yearsley: "The Problem of the Deaf School Child." 

Second International Congress for School Hygiene, vol. iii, 

1907, pp. 839-45. 
*21. Macleod Yearsley: "The Classification of the Deaf Child." 

Inter. Mag. School Hygiene, vol. vii, 1911, pp. 4-13. 
*22. Macleod Yearsley: "The Treatment of Suppurating Ears in 

School Children." School Hygiene, vol. viii, 1912, pp. 69-78. 



CHAPTER XIV 

THE HYGIENE OF VISION 
Written with the assistance of Dr. E. B. Hoag 

New demands upon the eye 

Excepting touch alone, the eye is the most valued 
of our special senses. The conservation of vision has 
been called "more important than all the work of our 
universities." At least one fourth of the inhabitants of 
Europe and America are more or less handicaj:%)ed by 
defective vision. Since most of the instruction given in 
the schools is based upon the visual impression, it is 
well to examine the efficiency of the visual functions to 
ascertain the effects of school work upon them. 

Most of the organs of the human body were molded 
in response to definite demands of life and environ- 
ment. These demands are the measures according to 
which nature has fashioned us. The eye is no exception 
to this law. Generally speaking, each animal species 
has developed as good vision as its mode of life calls for, 
and no better. "Perfection for perfection's sake" is 
foreign to the economy of nature. 

What kind of an eye did primitive man require? 
Plainly, one which would be effective chiefly for distant 
seeing, able to make as many as forty to fifty move- 
ments per minute, and one which could focus for a few 
minutes on near objects, if occasion demanded. For 



246 THE HYGIENE OF THE SCHOOL CHILD 

the bulk of the human race, little more than this was 
required of the eye until the last few hundred years. 
The eye was permitted, for the most part, to roam in 
freedom. It made only large movements and made 
them slowly. Fixation was rarely for more than a few 
seconds. When it tired of one kind of work it was 
usually free to change its activity. 

Quite recently, however, the eye has been subju- 
gated by the tyranny of print and sentenced to a tread- 
mill form of action for which it was never originally 
designed. In five minutes of reading the eye makes, 
ordinarily, over one thousand separated movements 
and as many fixations, each with "rifle-aim precision." 
This is probably as much work as it was earlier re- 
quired to do in one hour. The ciliary muscle, in ac- 
commodating the eye for near work, such as reading, 
probably expends as much energy in five minutes as 
formerly it was necessary to expend in a whole day of 
distant seeing. Moreover, the accommodation must 
shift in the reading of each line as the eyes move across 
the page from left to right, since only in the middle of 
the line are the two eyes equally near to the point of 
fixation. Add to these burdens the difficulties of too 
fine print, insufficient light, an unsuitable form of type, 
improperly colored paper, unhygienic spacing of let- 
ters, lines, or words, and the abuse to which the eye is 
now universally subjected at once becomes apparent. 

The few generations since printing was invented have 
not sufficed for the evolution of a better eye. The new 
work must be done with tools which were fashioned 



THE HYGIENE OF VISION M7 

for other purposes. Let us see with what success the 
work is done, with what cost of effort, and with what 
injury to the tools themselves. 

The mechanism of vision 

The eye, as every one knows, works upon the princi- 
ple of the ordinary camera. The retina is the photo- 
graphic plate, the pupil of the eye is the point of en- 
trance for the rays of light, and the crystalline lens 
corresponds to the lens of the camera. The lens, of 
course, serves merely to bring the rays of light to a 
focus on the retina or photographic plate. 

In the working of the visual camera four possibili- 
ties are always present : — 

(1) The distance from the lens to the retina may be 
exactly sufficient to permit rays of light from distant 
objects (parallel rays) to be brought to a focus upon 
the retina. (Fig. 17.) 
This condition is 
called * * emme tro- 
pia." The emme- 

^ . . FIG. 17 

tropic eye is the Emmetropic omormal eye. Parallel rays focused 

. , on the retina 

ideal eye, for it per- 
mits objects distant more than a few feet to be imaged 
upon the retina with perfect distinctness while the eye 
is at rest. 

(2) If the distance from the lens to the retina is too 
short, the parallel rays strike the retina before they 
have been brought to a focus, thus giving a blurred 



Pr- 
Pr- 




248 THE HYGIENE OF THE SCHOOL CHILD 




image. (Fig. 18.) This condition is "hyperopia," or 
"far-sight." Far-sighted people, however, do not see 

even distant ob- 
jects clearly when 
the eye is at rest; 
though the farther 

Hypermetropic or long-sighted eye. Rays of light away tlie ODJCCt IS, 
focused behind the retina , . • , • 

the less its image 
is blurred. Clear vision is possible for the hyperopia 
eye in one way only; namely, by an increase in the con- 
vexity of the lens sufficiently great to bring the parallel 
rays to a focus exactly on the retina. Fortunately, the 
crystalline lens is provided with a means for regulating 
its convexity. The action of this mechanism is known 
as "accommodation." Accommodation consists essen- 
tially in releasing the tension of the suspensory liga- 
ment of the lens through the action of the ciliary 
muscle. This enables the lens to increase its convexity 

by virtue of its 
inherent elastic- 
ity. When the 
ciliary muscle 
contracts, the 
pressure on the 
lens is in part 
released, permit- 
ting it, because 
of its elasticity, 
to assume a more nearly globular shape. (Fig. 19 .) The 
nearer the object is to the eye, the more the ciliary 




FIG. 19 
Diagram to illustrate accommodation. On the left, 
the form taken by the lens at rest and viewing dis- 
tant objects is shown ; on the right, that when ac- 
commodated for near objects. Sc, sclerotic ; C. P., 
ciliary processes ; Sp.L., suspensory ligament ; C.L., 
crystalline lens. (From Thornton's "Advanced 
Physiology.") 



THE HYGIENE OF VISION 249 

muscle must exert itself. It will be observed also that 
the emmetropic eye, the eye which focuses the rays 
from distant objects upon the retina without effort, 
must resort to accommodation when near objects are 
fixated. The normal eye can secure rest from the strain 

of accommodation simply by looking away from the 

» 

book or other near object to something in the distance, 
but the ciliary muscle of the badly hyperopic eye ordi- 
narily receives no rest. It can be relieved only by an 
artificial convex lens which, placed in front of the eye, 
takes the strain off the crystalline lens, so to speak, and 
places it upon the glasses. 

(3) Sometimes the eye is too long from front to 
back, so that parallel rays are brought to focus before 

they strike the re- 

tina. (Fig. 20.) p, ^ /^fV^ 

This condition is ^ ---^Z L.^\r ^^rr' 

known as "myo- ^-^ — ^ 

. „ (( FIG. 20 

pia, or near- Myopic or short-sighted eye. Rays of light focused 

• T , ,, T • i^ front of the retina 

Sight. In myopia 

there is no possibility of clear vision for distant ob- 
jects, since contraction of the ciliary muscle would 
increase the convexity of the lens and so make mat- 
ters worse. Objects close enough are distinctly imaged 
in myopia. But however great the myopia and how- 
ever badly it interferes with ordinary vision, no strain 
of accommodation results. The only eye-strain pro- 
duced by myopia is the strain upon the oculo-motor 
muscles which are attached at the rear of the eyeball. 
These, in looking at very near objects, must exert a 



250 THE HYGIENE OF THE SCHOOL CHILD 

constant pull to converge the two eyes upon the ob- 
ject, held, as is often the case, but a few inches dis- 
tant. 

(4) In the simple myopia and simple hyperopia just 
described the source of imperfection lies solely in the 
length of the anterior-posterior diameter of the eyeball. 
If this diameter is too short, we have hyperopia; if too 
long, myopia. But there is another source of defect; 
namely, uneven curvature of the cornea or lens (usu- 
ally the cornea). This is known as "astigmatism." In 
astigmatism the cornea (or else the lens) has "different 
curvatures in different meridians" (diameters), so that 
only blurred, or partly blurred, images are formed. The 
rays of light from an object may focus partly in front, 
partly behind, and partly on the retina. Five varieties 
of astigmatism are possible, as follows : — 

TABLE 26 

Varieties Focus from one Focus from other 

extreme diameter extreme diameter 

Simple hyperopic On retina and Behind retina 

Compound hyperopic Behind retina and Behind retina 

Simple myopic On retina and In front of retina 

Compound myopic In front of retina and In front of retina 

Mixed In front of retina and Behind retina 

If not too severe, most of the forms of astigmatism 
can be corrected, or partly corrected, by the action of 
the ciliary muscle. The same is true of hyperopia. If, in 
spite of the astigmatic or hyperopic shape of the eye, 
clear vision results by virtue of accommodation, we 
have the condition described as "latent astigmatism" 
or "latent hyperopia." Correction is made, but at the 



THE HYGIENE OF VISION 251 

cost of eye-strain. When the strain becomes too great 
and correction is no longer possible, the defect is 
described as "manifest." Hence astigmatism and hy- 
peropia are the two causes of overstrain of the ciliary 
muscle. Relief from astigmatism is secured by glasses 
ground in such a way as to have also "different curva- 
tures in different meridians," but the reverse of the 
difference between the two meridians of the eye and so 
correcting it. 

f Let us now consider each of the above conditions in 
greater detail. 

Emmetropia {correct vision) 

No human eye is absolutely perfect, and few even 
approximately so. The great Helmholz ^ is said to 
have remarked that he would instantly discharge any 
laboratory assistant who had prepared for his use an 
optical instrument as imperfect as the most perfect 
human eye. George M. Gould claims to have found 
no perfect eye out of 10,000 pairs examined (8). Jack- 
son (13) reports 51 eyes out of 4000 as emmetropic, or 
1.3 per cent. 

But nature's adaptations are seldom perfect, and 
faults of structure or functioning could probably be 
made out for almost any organ of the body. Slight 
imperfections of the eye do not greatly hinder vision, 
and from half to two thirds of the people get along 
fairly comfortably with the optical apparatus nature 
has given them. 

^ Physicist, physiological-psychologist, and inventor of the oph- 
thalmoscope. 



252 THE HYGIENE OF THE SCHOOL CHILD 

Not so, however, with a large minority. Of about 
500,000 children examined in the elementary schools of 
London, 10 per cent had not more than one third nor- 
mal vision. Examinations of 87,000 pupils in the Rus- 
sian secondary schools showed that the incidence of 
myopia alone ranged from 8.8 per cent in the lower 
grades to 22.6 per cent in the highest. 

Out of 79,065 children examined in the public schools 
of New York City (1906), 31 per cent are reported as 
having defective vision. For the entire State of Massa- 
chusetts (402,937 children) the proportion of children 
with defective vision was returned in 1907 as 22.3 per 
cent. In Cleveland (30,045 children) the proportion 
was 20.7 per cent; in Minneapolis (25,696 children), 
30 per cent; in Worcester (11,953 children), 19.1 per 
cent; suburban schools near St. Louis (2000 children), 
30.6 per cent. Dr. E. B. Hoag finds 30 per cent for 
15,000 children in the towns and cities of Minnesota. 

Statistics from about 165,000 school children in 
Japan gave the following results (18) : — 

TABLE 27 

Kind of school Number examined Defective vision 

'Middle schools 92,290 12.4 per cent 

Boys J Normal schools 11,963 16.6 

1 Technical schools 28,115 12.8 

Professional schools 1,631 28.8 

Girls r High schools 27,191 9.4 

\ Normal schools 4,018 7.6 

The above statistics, chosen from innumerable in- 
vestigations in diverse parts of the world, amply demon- 
strate that from 10 to 30 per cent of the school pop- 
ulation have vision sufficiently imperfect to demand 



THE HYGIENE OF VISION 253 

correction by glasses. The conditions in different cit- 
ies and countries are probably more uniform than 
the figures presented would indicate, the statistics 
depending in part upon the methods of testing and in 
part upon the varying standard as to the degree of 
defectiveness which may be safely disregarded. 

Hyperopia {'yar-sighf") 

As already explained, hyperopia is due to a too short 
diameter of the eye from front to back. Examinations 
made by various investigators of more than 2000 day- 
old babies prove conclusively that hyperopia is the 
normal condition at birth (29). As age increaisi^s, the 
eye changes gradually from the condition of hyper- 
opia to that of emmetropia (normal vision), and later, 
in many cases, to myopia. In London school children 
the proportion of hyperopia decreases rather regu- 
larly from 45 per cent at 6 years to 18 per cent at 13 
years. ^ 

Similar figures could be quoted in great number, but 
the following table of results from the Gymnasium at 
Altona, Germany, will sufficiently illustrate the law 
of decreasing hyperopia as the eye evolves. 

^ It is important to distinguish the hyperopia of childhood from 
the condition of far-sight commonly found in persons somewhat past 
middle age. The former condition is ordinarily due to the fact that 
the eye is undeveloped. The latter condition, known as "presby- 
opia," is due to the decrease in the power of accommodation which 
usually takes place after the age of thirty-five or forty years. Most 
persons at this age would do well to have the eyes tested for pres- 
byopia. 



254 THE HYGIENE OF THE SCHOOL CHILD 





TABLE 28 


Age 


Number hypermetropic 


9-11 


18.93 per cent 


12-14 


7.14 


15-17 


6.88 


18-20 


4.05 


21-22 


0.00 



The significance of hyperopia Hes chiefly in the 
strain it throws upon the ciKary muscle in the effort 
to produce accommodation. Another serious result 
frequently produced by hyperopia is "squint,'* or 
"cross-eye." ^ The emmetropic (normal) eye demands 
effort on the part of the ciliary muscle during "near 
work"; the hyperopic eye always. Any considerable 
degree of hyperopia, uncorrected by glasses, is there- 
fore a constant source of eye-strain. It is much the 
same as if any other muscles were compelled to work 
without a moment's rest except during sleep.^ 

Whether hyperopia should be corrected by glasses 
depends upon the degree of the defect, the age of the 
child, and the general condition of health. Mild hyper- 
opia in the early years is perfectly normal, and the only 
caution necessary in such cases is the avoidance of an 
excessive amount of near work. If the health is good, 
a fairly high degree of the defect may be corrected by 
accommodation without symptoms of eye-strain. On 

1 See p. 263. 

2 It should be stated, however, that if the degree of hyperopia is 
so great that the ciliary muscle cannot make even approximate cor- 
rection, the eflFort of accommodation is relaxed and the eye accepts 
the blurred vision as inevitable. In this event there is poor vision 
without eye-strain. 



THE HYGIENE OF VISION ^55 

the other hand, if the health is poor and the *'tone" 
of the muscles reduced, a relatively slight hyperopia 
may give rise to marked symptoms. The oculist alone 
is competent to judge whether glasses are needed. 

When the hyperopia is very great, correction by 
glasses is always necessary. Neglect of such children 
is nothing less than cruelty. The extremely hyperopic 
eye works as hard at distant vision as the normal eye 
at near work. Let the person with normal eyes focus 
them upon an object distant twelve inches and attempt 
to retain this focus for fifteen consecutive hours and he 
will gain an idea of the strain to which the extremely 
hyperopic person is all the time subjected. Litt]^ won- 
der that the nerves should be shattered and the general 
health disturbed by a strain so far beyond the power of 
any muscle to endure! 

Myopia 

No question in school hygiene has given rise to more 
controversy, or to more error, than myopia. Certain 
aspects of the problem which had been in dispute for 
over a hundred years are only now being cleared up, 
and the most erroneous statements are still common 
both in the literature of school hygiene and in medical 
treatises. 

Over half a century ago it was clearly shown by 
Cohn that myopia increases rapidly in the upper 
grades, reaching often as high as 40 or 50 per cent by 
the age of 20 years. This, it was assumed, was due en- 
tirely to the near work of the school. 



256 THE HYGIENE OF THE SCHOOL CHILD 

, It was assumed further that myopia of any degree 
is pathological and tends to run a progressive course. 
"The myopic eye is a diseased eye, and the school is its 
cause," was the slogan of reform. It was believed that 
the defect was produced solely by the excessive con- 
vergence required of the eyes when a near object is 
fixated, the pull of the oculo-motor muscles on the 
coats of the eye at the rear gradually lengthening the 
eye-ball. The myopia thus induced would, of course, 
require objects to be brought still nearer the eye for 
clear vision, which, in turn, would require still greater 
convergence, resulting in increased myopia, and so on. 
This is what is meant by the statement that myopia 
tends to be "progressive," or to run in a "vicious 
circle." It was also emphasized that finally the exces- 
sive pull required for convergence would inevitably 
result in other pathological conditions of the coats 
of the eye. 

Further proof of the contention that myopia is 
always pathological and that it is chiefly induced by 
the abuse of near vision was sought in statistics which 
purported to show that it is not present in primitive 
races, and that its frequency is always in proportion 
to the amount of near work required. Myopia came to 
be known as "school myopia." 

The defect was even considered by some writers an 
important factor in character formation, causing, it was 
believed, stubbornness, melancholia, timidity, abou- 
lia,^ phobias of people or ghosts, superstition, etc. 

^ Weakness of the will resulting in inability to make decisions. 



THE HYGIENE OF VISION 257 

On the other hand, opponents of this view have con- 
tended that school statistics always exaggerate the 
amount of myopia through frequent failure to distin- 
guish it from other forms of defective vision; that the 
much-talked-about pathological effects of myopia are 
discoverable only in rare cases; that severe myopia is 
not uncommon in children below school age and in 
uneducated peasants who have never gone to school 
or used their eyes for other forms of near work; and 
that whatever increase takes place during school life 
is in part the result of the natural evolution of the eye 
and in part represents a favorable adaptation of the 
eye to the demands made upon it. Some have ^ne so 
far as to assert that a moderate degree of myopia is the 
ideal condition, and that if it were possible to prevent 
myopia it would be a grave mistake to do so. 

Space does not permit us to enter into the details 
of this interesting Hundred Years' War, the wavering 
fortunes of which, as recorded in the narrative of 
Wingerath (29), read like a modern Iliad. 

Let us, if possible, escape the bias of the violent par- 
tisan and base our conclusions upon reliably established 
facts, remembering that the cause of school hygiene 
cannot be permanently served by an exaggeration of 
its claims. 

Among the essential facts are the following: — 

(1) Myopia is by no means unknown among primi- 
tive races, though its exact frequency has not been 
sufficiently established for many tribes. 

(2) Investigations of eye conditions among army 



258 THE HYGIENE OF THE SCHOOL CHILD 

recruits in Germany and Denmark have revealed the 
presence of all degrees of myopia in recruits who had 
never attended school or engaged in near work of any 
kind. Although most of these studies agree in finding 
a larger proportion of myopia among recruits who had 
attended school longest, one investigation, at least, 
finds exactly the reverse. 

(3) The fact that myopia becomes much more fre- 
quent in the upper grades is admitted by all, but that 
the school is the chief culprit remains to be proved. The 
evolution of the eye from a condition of hyperopia to 
one of myopia has been frequently observed among 
those who have attended school little or none at all. 
The presence of more myopes in the upper classes is 
also partly accounted for on the theory that inasmuch 
as extreme near-sight unfits the child for ordinary dis- 
tant seeing but leaves the ability to read little impaired, 
children with myopia are for this reason more likely to 
be retained in school and to crowd the upper grades. 

The most reliable statistics, such as those of Red- 
slob (21), Krusius (15), and Khlopine indicate that 
myopia is about as common in those types of schools 
demanding the least amount of near work as in those 
demanding most. Moreover, no very appreciable de- 
crease in the proportion of myopes among school 
children seems to have taken place as the result of the 
modern crusade for school-hygiene reform, although re- 
markable advances have been made in school-lighting, 
bookmaking, etc. While it cannot be denied that the 
school may be one factor in the production of myopia, 



THE HYGIENE OF VISION 259 

that it is the sole, or even the chief, factor can no 
longer be maintained. 

(4) The investigations of Stilling, Steiger, Miss 
Barrington, and Karl Pearson amply demonstrate 
the hereditary character of myopia. On the basis of 
more than 5000 measurements made on cadavers. 
Stilling claims that the development of myopia is 
mainly dependent on the conformation of the bony 
socket of the eye, a low orbit predisposing to the defect. 
This, of course, is hereditary in the same degree as any 
other skeletal peculiarity. 

(5) It will be impossible to clear up the mysteries of 
myopia as long as all kinds and degrees of th^defect 
are thrown together for wholesale consideration. As 
regards both the cause and the results of myopia, it is 
necessary to distinguish two types: (a) pathological 
myopia, and (b) functional myopia. 

Pathological myopia is usually of high degree and 
represents a definitely diseased condition of great seri- 
ousness. Of this type, it is correct to say that "the 
myopic eye is a sick eye"; and we may add that it is 
myopic largely because it is sick, not sick simply be- 
cause it is myopic. This form of myopia runs a pro- 
gressive course. 

Functional myopia, on the contrary, is usually of 
low degree, appears ordinarily in late childhood or 
early adolescence, and becomes fully arrested before 
the age of twenty-five. The best authorities at present 
believe that this type of myopia rarely, if ever, passes 
over into the pathological type. It is a defect which, 



260 THE HYGIENE OF THE SCHOOL CHILD 

although it may handicap its possessor for certain 
kinds of work, is unKkely to have serious consequences. 
In all probability it is the joint product of two factors : 

(a) a low orbit (which is hereditary), and (6) an exces- 
sive amount of near work, such as reading, writing, 
sewing, etc. It has not been demonstrated that factor 

(b) operating alone is responsible for any large pro- 
portion of the cases. 

(6) The functions of school hygiene with respect to 
myopia are fairly definite. In the first place, it is ex- 
tremely important to identify those children who have 
a tendency to "pathological myopia." These should 
remain under the constant supervision of the oculist. 
In the second place, the school should do everything 
possible to clear itself from the suspicion of causing 
"functional myopia." Lighting, seating, textbooks, 
and the hygienic arrangement of the daily program, 
including rest periods, are the cardinal points here. If 
it is correct, as seems probable, that the chief cause of 
myopia lies in the shape of the eye's orbit, then it 
would be possible 'to identify in the first grade those 
who are likely to develop the defect later. Appropriate 
means could then be employed to safeguard such chil- 
dren from needless injury to their sight. ^ 

Astigmatism.'^ 

The discovery of astigmatism by Thomas Young 

over a hundred years ago, and the later demonstration 

^ See the admirable discussion of myopia by Professor W. H. 
Burnham, in Monroe's Encyclopedia of Education. 
2 For definition see p. 250. 



THE HYGIENE OF VISION 261 

by Donders that it is due to an error of refraction, 
constitute, together, one of the most important medi- 
cal advances of the last century. Astigmatism is re- 
sponsible for more than half the cases of seriously im- 
paired vision and for the majority of cases of eye-strain. 

In the period 1908-11, the school physicians of 
Strassburg referred 2033 children to the school oculist 
for special examinations. Among these there were 679 
eyes hyperopic, 588 myopic, and 1496 astigmatic. 
Astigmatism was, therefore, more than 17 per cent 
more frequent than hyperopia and myopia combined. 

Few eyes are entirely free from astigmatism. Of 
2307 school children examined by Dr. Stoofcer, in 
Lucerne, Switzerland, 96.7 per cent had astigmatism 
of at least .25 D in one or both eyes. Statistics usually 
show that not far from 10 or 15 per cent of the school 
children have astigmatism sufficiently great to impair 
vision seriously. The statistics secured by Steiger 
(24) are typical. In the cities of Zurich and Berne 
(Switzerland), 7736 children out of 25,995 whose ages 
lay between 6 and 8 years were referred to the school 
oculist. Dr. Steiger, for examination. Of these, 2406, 
or slightly less than 10 per cent of the 25,995, were 
found to be markedly astigmatic. 

Some forms of astigmatism impose a peculiarly diffi- 
cult task upon the ciliary muscle in the effort of correc- 
tion. Sometimes it causes faulty posture, since the 
child sees more clearly in one meridian than in the other 
and so turns the head to one side in order to take ad- 
vantage of the meridian of clear vision. It is possible 



262 THE HYGIENE OF THE SCHOOL CHILD 

that preferences as regards handwriting slant are 
sometimes caused by the astigmatic eye choosing that 
slant which makes the individual lines stand out most 
clearly. 

Whether the child with a moderate degree of astig- 
matism should be advised to secure glasses depends in 
large measure upon the state of health. In some chil- 
dren, rather severe errors of refraction cause no dis- 
coverable symptoms; in others, marked symptoms 
accompany slight errors. Some eyes have little power 
of correction, and some nervous systems are more 
subject to reflex disturbances than others. 

There is no evidence that astigmatism is caused by 
the school, though of course near work adds very 
greatly to the burden of the astigmatic eye and aggra- 
vates the symptoms of strain. The cause, in most 
cases, is the pressure exerted by the eyelids upon the 
ball. Astigmatism in the opposite direction, '* con- 
trary to the rule," is much more rare in children than 
in adults, making up onl^^ 2.9 per cent of all the cases 
of astigmatism found by Redslob (21). 

Muscular deviations 

The muscles which move the eyeball are subject to 
three common varieties of disturbance, resulting re- 
spectively in squint, unbalance, and muscular insuf- 
ficiency. The cause of squint and unbalance is usually 
some form of ametropia (i.e., far-sight, near-sight, or 
astigmatism), and not chiefly an anatomic defect in 
the muscles or their attachment, as was formerly 



THE HYGIENE OF VISION 263 

believed. Paralysis will, of course, produce muscular 
deviations, but aside from this the cause is usually 
some refractive error. 

Squint, or "cross-eye," is a particularly serious con- 
dition of muscular disturbance often observed in school 
children. The experience of Dr. E. B. Hoag indicates 
that it can be detected in about 2 per cent of the school 
enrollment by means of ordinary observation, with- 
out the use of any optical instruments, Cornell esti- 
mates that it is present in from 3 to 6 per cent (5), 
while Butterworth finds that it ranges around 2 per 
cent. 

In the majority of instances, squint is camsed by 
congenital and excessive hyperopia in one of the eyes. 
The child early learns instinctively to disregard the 
"bad eye," which is soon turned up, down, in, or out. 
As a result, the power to focus is soon lost in this eye, 
and if proper glasses are not obtained before the child 
is 6 or 7 years old (or even earlier), the sight of the 
crossed eye is usually greatly reduced or even lost alto- 
gether. Some believe that the reduced vision comes 
solely from disuse; others that it is occasioned by a 
lack of development in that portion of the brain which 
is concerned with the vision of the eye. 

If the eyes are to be straightened without operation 
and the sight saved, glasses and treatment must be 
provided at the earliest possible moment, even if the 
child is still an infant in arms. Every medical examiner 
sees many cases of squint in which the vision is almost 
or quite destroyed in the eye affected. Parents and 



264 THE HYGIENE OF THE SCHOOL CHILD 

teachers rarely understand the situation, and are as- 
tonished to learn that the child's vision is already seri- 
ously affected or past repair. 

The study of Butterworth, already mentioned, is 
perhaps the most valuable in this field. Of 14,739 
children whom he examined, 3 to 13 years of age, 2.2 
per cent had the defect. The number increased from 
3 to 6 years, after which it remained practically sta- 
tionary. We may say, therefore, that if the child has 
binocular vision when he enters school, he is not likely 
to lose it later. The left eye, for reasons unknown, was 
affected nearly twice as often as the right eye. Only 
one fifth of Butterworth's cases had ever used glasses, 
and only the insignificant number of one twenty -fifth 
of these had completely regained binocular vision, the 
treatment in most cases having come too late. 

Many individuals suffer from slight unbalance of 
the oculo-motor muscles without noticeable squint. 
In such cases there is either constant or occasional 
impairment of binocular vision, and always a nervous 
strain from the effort to balance the eyes in maintain- 
ing steady focus. The strain may be unnoticed and 
binocular vision retained as long as health is good, 
while after an illness or during extreme fatigue the 
nervous symptoms of strain may appear and binocu- 
lar vision become intermittent or altogether impossible. 

Eye-strain in relation to visual defects 

As already explained, eye-strain may result either 
from (a) overuse of the ciliary muscle in producing 



THE HYGIENE OF VISION 265 

accommodation, or (b) excessive effort on the part of 
the oculo-motor muscles in maintaining eye-balance 
and producing convergence. The former is the more 
common cause. 

The strain of accommodation is constant in the hy- 
per opic eye, and is more severe the nearer the object 
is which is fixated. Astigmatism nearly always results 
in greater or less strain. In the normal eye, also, there 
is strain of accommodation as long as near work is 
being performed. 

Due to the power of accommodation, not all people 
who have imperfect eyes suffer radical impairment of 
vision. Excessive use of accommodation in far-§ighted 
and astigmatic persons, however, always finally results 
in eye-strain. This is particularly likely to occur in 
those individuals whose work requires considerable 
near vision. In outdoor work requiring only little use 
of the eyes for near vision, no symptoms may appear 
even in the case of serious defectiveness, provided the 
general health is good. 

The close relation existing between general physical 
condition and the power of accommodation is well 
demonstrated by the experiments of Bauer. ^ Testing 
the range of accommodation at different times in the 
day, before and after various kinds of work, Bauer finds 
that it closely parallels the daily course of physical 
and mental efficiency and serves as an excellent meas- 
ure of fatigue. The accompanying figure from Bauer, 
in which vertical distance represents the range of ac- 
^ Die Ermiidung in Spiegel des Auges. 1910. 



^66 THE HYGIENE OF THE SCHOOL CHILD 

commodative power and horizontal distance refers to 
the time of day, shows the intimate connection be- 
tween fatigue and the functional capacity of the ciliary 
muscle. 

There are few things more important for the teacher 
to understand than the injuries produced by eye-strain, 





Mon. 


Tues.. 


Wei. 


Thurs. 


Fri. 


Sat. 


Sun.. 


Hour 


8 12 2 4 


8 12 2 4 


8 12 2 4 


8 12 2 4 


8 12 2 .4 


8 12 2 4 


8 12 2 4 


60 




















11 


I 








50 




|\ 


\ 


ft 








A 


M 






|\ 






40 


A 




n 




V 






l\ 


, 




w 




\ 




30 


I 


V 


1 


j \ 


j 


\ 




/ 


1 


1 


f 


i 




^^"^--^ 




/ 






If 








20 
CM 

















FIG. 21 
Showing the daily curve of fatigue for eye accommodation during an entire week 
for one subject. Vertical distance, represented in centimeters, shows the dis- 
tance for which accommodation was possible at different times in the day. 
Greater vertical distance corresponds to a higher degree of fatigue. Note that 
accommodation is best at 8 a.m. and worst at noon. Note absence of fatigue 
on Saturday and Sunday. 

since it not only produces local symptoms and im- 
perfect vision, but through its reflex effects may also 
undermine health altogether. It would almost seem 
as if the whole reservoir of nervous energy could be 
exhausted through this one small leak. 

The signs and symptoms of eye-strain may be clas- 



THE HYGIENE OF VISION 267 

sified as local or general. The chief local manifestations 
are: — 

(1) Painful eyes; 

(2) Spasms of the eyelids; 

(3) Itching, smarting, or watering of the eyes; 

(4) Congestion of the eyes; 

(5) Sensitiveness to light; 

(6) Frowning; 

(7) Blurred vision. 

In regard to blurred vision, some interesting and very 
significant answers are obtained when children in the 
schools are asked the question, "How does the print 
look to you?" The following are representative ver- 
batim answers recorded by Dr. Hoag in his worK with 
thousands of pupils in California and Minnesota. 
Of one group of over 5000 pupils thus questioned, 23 
per cent gave such answers as the following : — 

"The letters all run together." 

"I see two lines instead of one." 

"I see one letter on top of another.", 

"The letters look crooked." 

"The print seems all jumbled up." 

"The letters jump up and down." 

"After I read awhile, I can't find my place any more." 

"The print looks like a big blot." 

"The letters seem like a fog was over them." 

"The letters look half up-side-down." 

The reflex, or general, symptoms of eye-strain are 
legion. Among the most important are : — 

(1) Headache (often with nausea) ; 

(2) Feelings of exhaustion and weakness; 



268 THE HYGIENE OF THE SCHOOL CHILD 

(3) Indigestion (sometimes constipation) ; 

(4) Dizziness; 

(5) Sleeplessness; 

(6) Neurasthenia (fatigue of the nervous system) ; 

(7) Motor disturbances, such as twitching, automatisms, 
stuttering, etc.; 

(8) Irritability, lack of emotional control, outbreaks of 
temper, etc. 

Of the reflex symptoms, headaches are the most 
important. Cornell finds that 31 per cent of those who 
have eye-strain suffer frequent headaches. Conversely, 
headaches (particularly those localized in the frontal 
region of the head) should always suggest the possibil- 
ity of eye-strain.^ 

It is quite generally admitted that eye-strain is 
sometimes responsible for one or more of the other 
general symptoms above listed, though not all are 
ordinarily present in any one case. There is reason to 
believe, also, that it may occasionally act as the pro- 
verbial "last straw" in the production of chorea, 
habit-spasms, moral delinquency, or even functional 
epilepsy. 

Teachers should never forget that ability to read the 
vision charts at the normal distance is no guaranty 
that eye-strain is not present. In many cases of fairly 
severe hyperopia and astigmatism, the child is able to 
read the chart simply by bringing an excessive amount 
of accommodation into play. The only means of ascer- 
taining the actual refractive error of the eye, and there- 
fore the amount of strain to which it is subjected, is to 

^ See chapter xv. 



THE HYGIENE OF VISION 269 

prevent accommodation during the test by paralyzing 
the cihary muscle. This the oculist accomplishes by 
dropping into the eye one of the forms of belladonna. 

Since this precaution cannot be taken in routine 
examinations of eyes by the teachers or school doctors, 
it is extremely important that the teacher be able to 
supplement the tests by the detection of the general 
and local symptoms of eye-strain. Because of her con- 
stant presence with the children during their near work, 
the teacher is in better position to discover such symp- 
toms than the school doctor or any one else. Children 
in whom teachers observe either general or local symp- 
toms of eye-strain should be referred to the oculist for 
thorough examination. There should be a school ocu- 
list for this purpose. If there is none, the parents should 
be urged to avoid the risky but common practice of 
consulting an optician.^ There are so many possible 
sources of error in prescribing for glasses,^ that only 
the expert should be entrusted with it. 

Directions for testing the vision of school children^ 

In testing the eyes of children in the schools no elab- 
orate optical apparatus is essential, or, indeed, desir- 
able. The tests may and ought to be made by every 
teacher and the results carefully recorded for use. Dr. 

^ An oculist is a physician who has specialized on the diseases and 
disabilities of the eye. An optician is a person who makes or sells 
glasses. 

^ At least seventy-eight, according to Dr. Gould. 

' .This section has been prepared with the assistance of Dr. Frank 
Allport, of Northwestern University, to whom the author is indebted 
for many kindnesses. 



270 THE HYGIENE OF THE SCHOOL CHILD 

Frank Allport, Dr. R. C. Cabot, Dr. Myles Standish, 
Dr. Clarence Blake, and other oculists of the highest 
standing, have long contended that the ordinary rou- 
tine examinations of the eyes should be undertaken by 
teachers and school nurses. The teacher can make the 
tests fully as well as can the physician who is not also 
an oculist, and by virtue of her constant opportunity 
to observe the symptoms of eye-strain among her pupils 
she is in even better position than the school doctor 
to single out the children who need to be referred to an 
oculist. The tests will reveal the worst cases of defec- 
tive vision, and symptoms of eye-strain will reveal 
many others if the teacher is observant. In the words 
of Allport, ''Teachers should not attempt to diagnose 
diseases, but by means of simple tests, tests which can 
be given by any one with intelligence enough to teach, 
they can detect almost all serious diseases and defects 
of the eye, ear, nose, and throat. The doctor consulted 
will do the rest." 

By this means, all the pupils of a school system, how- 
ever large, can be tested for vision in one day; or, if 
preferred, a few pupils can be examined each day until 
the work is completed. "The teacher should by no 
means regard such tests as a hardship. By giving only 
a little time to them she will lighten her labors by 
sometimes transforming the nerve-exhausting, bother- 
some, and retarded pupil into one who is easily taught 
and ordinarily tractable.'* 

For carrying out these tests each school should be 
supplied with one of the standard eye-charts made for 



THE HYGIENE OF VISION 271 

this purpose. The Allport charts are to be recom- 
mended for the reason that they are designed for the 
special use of teachers and nurses. Full instructions 
are printed at the bottom of the chart. This part may 
readily be detached and kept before the examiner for 
convenient reference while the test is being given. The 
Allport charts have also the advantage of cheapness, 
the price quoted being but seven cents each in quanti- 
ties of ten or more. Single charts may be had for 
twenty-five cents. At the price of seven cents there is 
no school system which cannot afford to supply a vi- 
sion chart for every classroom.^ 

In testing the eyes of young children the caWs de- 
vised by McCallie are very desirable. ^ These consist 
of a series of small cards on each of which is a boy, 
a girl, and a bear. The test requires the child to tell 
who has the ball (a black dot visible at twenty feet). 

In no case should the vision test be made when 
the child has a cold in the eyes, or when they are in- 
flamed from other causes. 

Teachers and nurses will do well to be cautious in 
recording the results of vision tests, as there is a con- 
stant tendency to overestimate the number of defects. 
All children are likely to miscall and transpose certain 
letters, and this must be taken into account. It is only 
required that the child read the majority of the letters 
at the required distance without undue hesitation. In 

^ The charts may be purchased of F. A. Hardy & Co., Wabash 
Avenue, Chicago, Illinois. 

2 Edwin Fitzgeorge, agent, Trenton, New Jersey. 



m THE HYGIENE OF THE SCHOOL CHILD 

general it will be discovered that, when tested by the 
rough methods here indicated, from 15 to 30 per cent 
of school children have defective vision. Results which 
run much above or below these figures must ordinarily 
be suspected of containing error. 

For practical purposes the chart for testing astig- 
matism is of little value in routine school work. The 
absolute necessity of observing and recording every 
case of crossed-eye should not be forgotten. 

Sometime before the child leaves school he should 
also be given the test for color-blindness. This is best 
done by means of the Holmgren wool test. To make 
the test quickly, place before the child a green skein 
of Holmgren worsted and have him match it from a 
bunch of "confusion skeins" of different colors. If this 
is done quickly and without hesitation the child is 
passed.^ 

About 4 per cent of the boys and one half of 1 per 
cent of the girls are more or less color-blind, inability 
to distinguish red and green being the most common 
form of the defect. Tests for color-blindness are quite 
necessary in the case of those who expect to take up 
such work as railroading, marine service, medicine, 
painting, chemistry, mineralogy, certain mercantile 
businesses, etc. Simply to let the child name the colors 
of things shown him is not sufficient. Color-blind 
persons often learn the right names for colors merely 
by their differences in brightness, while, on the other 

* More accurate tests for color-blindness and color-weakness may 
be found in Whipple's Manual of Mental and Physical Tests. 



THE HYGIENE OF VISION 273 

hand, some children who are not color-bhnd do not 
know the names for the different colors. Hence the 
necessity of the Holmgren test. 

Summary and conclusions 

(1) From 15 to 30 per cent of school children have 
seriously defective vision. This would mean that in 
the public schools of the United States there are from 
3,000,000 to 6,000,000 such children. 

(2) It is now known that the part played by the 
school in causing eye defects is not as serious as it was 
formerly believed to be. This is particularly true of 
myopia, in the production of which the shape*of the 
orbit of the eye (which is a matter of heredity) is prob- 
ably the leading factor. Near work, however, favors 
the development of the defect. 

(3) While the school is not a leading cause of refrac- 
tive errors of vision, its responsibility in relation to the 
eye is very great. This responsibility lies chiefly in the 
avoidance of eye-strain. The biological development of 
the eye has not fitted it for the kind of work which the 
school predominantly requires. Eye-strain is usually 
present in astigmatism and hyperopia, and the normal 
eye itself may suffer strain from the abuse of near 
work. 

(4) Eye defects are intimately related to faulty pos- 
ture, both as cause and effect. Myopia often leads to 
stoop shoulders, and astigmatism is one factor in pro- 
ducing lateral curvatures. Conversely, stooping pos- 
tures and habits of holding the book too near the eyes 



274 THE HYGIENE OF THE SCHOOL CHILD 

often cause eye-strain and favor the development of 
functional myopia. 

(5) Tests of vision in the school should be made by 
teachers and school nurses. This not only results in a 
great saving of expense, but is the only plan which gives 
the teachers the intimate knowledge which they need 
to have regarding the eye conditions of their pupils. 
By linking this knowledge with the daily observations 
of eye-strain symptoms, teachers will be better able 
than the school physician to single out those children 
who need to be examined by an oculist. 

(6) Schools have not paid suflScient attention to the 
correction of eye defects. Too often the parents neg- 
lect the advice of the school altogether or else resort 
to the optician for prescriptions. The experience of 
Strassburg, Zurich, Berne, and certain English cities 
proves conclusively that the one effective way to secure 
results in this field is by the employment of school ocu- 
lists in sufficient numbers to make a thorough exami- 
nation of all the cases of defective vision discovered by 
the teacher, nurse, or school doctor. Where this is done, 
practically all the children who are advised to do so 
present themselves for such examinations and nearly 
all secure the glasses needed. By the plan usually fol- 
lowed in America seldom more than 30 to 40 per cent of 
the eye defects are reported as treated, and the propor- 
tion of adequate treatments must be very low indeed.^ 
A further guaranty of results is the plan, quite preva- 

1 See Gulick and Ayres,. The Medical Inspection of Schools, 1913 
edition, pp. 92 ff. 



THE HYGIENE OF VISION 275 

lent in England, of supplying the glasses at wholesale 
prices, or even gratuitously in cases of poverty. A 
great saving is thus effected, and the purpose of the 
whole scheme of effort is attained to an extent possible 
in no other way. The argument that the private prac- 
titioner may suffer from the adoption of this plan has 
no weight. Eye defects, like all others which afflict 
school children, are to be conceived as an evil to be 
corrected, not as a resource to be conserved for the 
benefit of private individuals. 

(7) The school should take greater precaution than 
it ordinarily has done to secure the early diagnosis (and 
correction) of refractive errors. It is foolish to withhold 
relief until eye-strain has aggravated the defect and 
jeopardized the entire health of the child. The exam- 
inations in the first school year are, therefore, especially 
important. 

(8) The defect once discovered, its course should be 
followed from year to year. The child's eye is a devel- 
oping eye, and the glasses, in many cases, need to be 
changed occasionally. 

(9) When the condition of the eyes is such that sight 
is likely to deteriorate gravely or to be lost, the child's 
parents should be fully informed and the education of 
the child should be especially planned to prepare him 
for this contingency. The remnant of vision which 
remains should be utilized in preparation for the dark- 
ness which is to follow. Special schools are, therefore, 
desirable for the children who do not quite belong in 
an institution for the blind, but whose vision is too 



276 THE HYGIENE OF THE SCHOOL CHILD 

seriously impaired to enable them to profit normally 
from the instruction of the regular class. 

(10) The lighting of the schoolroom is often far from 
adequate. The light should amount to ten meter can- 
dles at the darkest corner of the room. To secure this 
in all kinds of weather and at all seasons, the window 
space should ordinarily be not far from one fourth of 
the floor space. ^ The light should strike the desk from 
the left and rear, never from the front. Spots and 
streaks of direct sunlight should be avoided. The ceil- 
ing should be almost white and the walls a light buff. 
Beamed ceilings and low windows are never permissible 
in schoolrooms. Window shades are often quite neces- 
sary, but they need to be managed with great care to 
prevent streaks of light, the shutting-off of lights from 
the wrong part of the window, too much darkening of 
the room, etc. They should be of linen and of light yel- 
low color. Nothing can be worse than the usual 
opaque, green shade. 

(11) Since school work, at best, is likely to result in 
abuse of the visual mechanism, special attention should 
be given to such matters as rest periods, size of hand- 
writing, the hygiene of textbooks, etc. All children 
should be taught to look off the book frequently. The 
morning session of three hours should be broken by two 
outdoor recesses of at least ten minutes each, and the 

^ Tests show that an average schoolroom in the central part of the 
United States may receive only about 18 per cent as much light in 
December as in June, and only 27 per cent as much at 4.30 p.m. as at 
noon. 



THE HYGIENE OF VISION 277 

afternoon session by at least one. The role of the eye in 
school instruction should be reduced to a minimum and 
more effort should be made to reach the mind through 
the ear and through the motor-activity. It is the duty 
of the school to teach children habits of economy in the 
use of the eyes. 

Schoolbooks should be made of white paper, without 
gloss; the lines should be short (preferably about three 
inches), the margins wide and the print large. The fol- 
lowing samples, according to Shaw and Huey, illustrate 
the minimum standards as regards size of type, spac- 
ing, etc. 

"Then there is a tnrn in the 
road. The long train runs over 
the bridge and swings round 
behind a hill. 

"The children cannot see it 
now." 

Minimum standard for first year 
(Size of type at least 2.6 millimeters and width of leading 
4.5 millimeters.) 

'' She must climb the tree. She held 
on, first to one branch and then to an- 
other, and tried to reach the golden 



278 THE HYGIENE OF THE SCHOOL CHILD 

plums. Her hands, her face, and her feet 
were scratched and torn by the thorns.'' 

Minimum standard for second and third years 
(Letters not smaller than 2 millimeters, with a leading of 
4 millimeters.) 

" On the way down, an Indian who was in a 
canoe stole something from the ship. One of 
the crew saw the Indian commit the theft, and, 
picking up a gun, shot and killed him. This 
made the other Indians very angry and Hud- 
son had several fights with them." 

Minimum standard for fourth year 
(Letters at least 1.8 millimeters, with leading 3.6 milli- 
meters.) 

(12) The handwriting should be large and oval. In 
the first grades blackboards should largely replace 
book and pencil. 

(13) It is imperative to remember that the eye of 
the school child is an undeveloped eye, and that for 
this reason it should be protected from overwork. 

(14) On leaving school , children with defective vision 
should have vocational advice. Much good would be 
done in such cases by placing in the hands of child and 
parent a card on which are listed the leading trades 
and professions in order of their tax upon vision. 

(15) Children whose eyes are inflamed or discharg- 
ing, or whose eyelids are swollen and red, should be 



THE HYGIENE OF VISION 279 

referred to the school physician for examination. There 
are many cases of contagious eye disease in the school, 
and for this reason the common towel should be abol- 
ished.^ 

Some indications of eye defects 

Crossed eyes; 

Peculiar head postures; 

Frowning; 

Holding book near the eyes; 

Difficulty in reading the work on the blackboard; 

Congested eyes; 

"Sore eyes," or granulated lids; 

Sensitiveness to light; 

Headache (one of the most common symptoms) ; ^ 

Fatigue; 

Nervousness; 

Poor spelling; 

Poor reading (miscalling words, etc.) ; 

Blurred vision; 

Double vision; 

Scars on cornea (usually from ulcers) ; 

Complaints of seeing colors or movement of letters or lines. 

SELECTED REFERENCES 2 

*1. Frank Allport:" The Eyes and Ears of Schoolchildren." Inter. 
Mag. Sch. Hyg., 1907, pp. 20-36. 

*2. A. Barrington and Karl Pearson: "A First Study of the Inheri- 
tance of Vision and of the Relative Influence of Heredity on 
Sight." Eugenics Lab. Memoirs, vol. v, 1909. 

*3. W. H. Burnham: Articles on "Myopia," "Hyperopia," "Astig- 
matism," and "Hygiene of the Eye," in Monroe's Encyclope- 
dia of Education. 1912. 

* For a discussion of contagious eye diseases see Hoag and Ter- 
man: Health Work in the Schools. 1914. (Chapter on "Transmissi- 
ble Diseases.") 

2 For references which have chiefly historical value see Winge- 
rath: Kurzsichtigkeit u. Schule. 1910, pp. 122-27. 



280 THE HYGIENE OF THE SCHOOL CHILD 

4. J. J. Butterworth: "An Analysis of 328 Cases of Squint." 

School Hygiene, 1911, pp. 449-53. 
*5. W. S. Cornell: The Health and Medical Supervision of School 
Children. 1912, pp. 201-43 and 578-84. 

6. Auguste Dufour: "La myopie scolaire." Third International 
Congress of School Hygiene, 1910, pp. 618-25. 

7. George M. Gould: Biographic Clinics, 1903 and 1904. 

8. George M. Gould: "The Cause, Nature, and Consequences of 
Eye-Strain." Popular Science Monthly, 1905, pp. 736-47. 

9. N. Bishop Harmon: "Eyes and Vision of School Children." 
School Hygiene, August, 1910. 

10. Franz Heilborn: "Zur Bekampfung der Schulmyopia." Inter. 
Mag. Sch. Hyg., 1910, pp. 14-21. 

11. Rudolf Held: " Die Kurzsichtigkeit unter den Gewerbelehr- 
lingen der Munchner Fortbildungschulen." Zt. f. Schulges., 
1912, pp. 801-06. 

*12. E. B. Huey: The Psychology and Pedagogy of Reading. 1908, 

pp. 15-50 and 387-431. 
*13. Edward Jackson: "Normal and Abnormal Refractions." In 

Randall and de Schweinnitz's American Textbook for Diseases 

of the Eye, Ear, Nose and Throat, pp. 212-35. 

14. R. Kaz: "L'Inspection oculistique des ecoles en Russe, 1902- 
1912." Inter. Mag. Sch. Hyg., 1912, pp. 375-84. 

15. Dr. Franz Krusius: "Einige Ergebnissen vergleichender Aug- 
enuntersuchung der hoheren Schulen der Provinz Branden- 
burg." Beiheft sur Zt.f. Schulges., August, 1912, pp. 95-105. 

16. Dr. Le Prince: "Myopie scolaire; Traitement, Hygiene, et 
Prophylaxie." Third International Congress of School Hygiene, 
1910, pp. 604-17. 

17. J. M. McCallie: "Vision of Pupils tested by Alphabefic and 
Illiterate Cards." Psych. Clinic, 1907, pp. 175-82. 

18. T. Misawa:" A Few Statistical Facts from Japan." Ped. Sem., 
1909, pp. 104-12. 

*19. "W. li.Pyle: Personal Hygiene. 1912 edition. (Chapter on " The 

Hygiene of the Eye.") 
20. A. L. Ranney: Eye-Strain in Health and Disease, 1897, pp. 

321. 
*21. Edmund Redslob: "Volksschule u. Auge. Die Augenarztliche 

Tatigkeit in den Volksschulen Strassburgs." Inter. Mag. Sch. 

Hyg., 1912, pp. 336-55. 

22. W. H. R. Rivers: "Vision." Repts. of Cambridge Anthropo- 
logical Expedition to Torres Straits, 1901, vol. ii, part i, pp. 8- 
140. 

23. Myles Standish: "Facts and Fallacies in the Examination of 
Children's Eyes." Proc. N.E.A., 1903, pp. 1020-23. 

*24. A. Steiger: "Schule u. Astigmatismus." First International 
Congress of School Hygiene, vol. iii, pp. 483-94. 

*25. A. Steiger: "Gedanken ii. d. verschiedenen Formen der Kurz- 
sichtigkeit." Arch.f. Rassen u. Gesellschafts-Biologie, 1908, pp. 
32-45. 



THE HYGIENE OF VISION 281 

*26. J. Stilling: Die Kurzsichtigkeit ; ihre Entstehung u. Bedeutung. 
Berlin, 1903. 

27. A. E. Taussig: "The Prevalence of Aural and Visual Defects 
among Public-School Children of St. Louis County, Missouri." 
Psych. Clinic, 1909, pp. 149-60. 

28. H. True: "L'Eclairage naturel des ecoles." Third Interna- 
tional Congress of School Hygiene, 1910, pp. 593-99, 

*29. Dr. Wingerath: Kurzsichtigkeit u. Schule. 1910, pp. 127. 

*30. Dr. Wingerath: " Allmahlicher Verlauf der Kurzsichtigkeit- 

bewegung bis zu ihren Wendepunkte." Zt. /. Schulges., 1912, 

pp. 321-43. 



CHAPTER XV 

THE HEADACHES OF SCHOOL CHILDREN 

Frequency 

Headaches seldom appear before school age, but in 
later childhood and throughout adolescence they are 
one of the leading symptoms of an unhealthy nervous 
condition. The Norwegian Commission of 1891 found 
occasional or frequent headaches among 27 per cent of 
the children of the secondary schools, 8 to 18 years of 
age. The investigations made in the same country by 
Hoist and Magelssen ten years later gave 17 per cent. 
Hertel's study of morbidity in the secondary schools of 
Copenhagen showed an average of about 7.5 to 14 per 
cent of the boys and from 7 per cent to 30 per cent of the 
girls suffering from headaches, the proportion for both 
being considerably higher for the ages 12 to 16 than 
for any other years. Schmid-Monnard's data for head- 
aches and other nervous states, taken together, are 
presented on pages 383-84. For 103,666 children in the 
secondary schools of Russia, Khlopine found a gradual 
increase in frequency of headaches from 6 per cent in 
the lowest grade to 12 per cent in the seventh. Of 
10,000 Minnesota school children questioned by Dr. 
E. B. Hoag, 25 per cent suffered "frequently" from 
headache. Among untold thousands of children head- 
ache is a chronic ailment. 



THE HEADACHES OF SCHOOL CHILDREN 283 

Causes 

The great excess of headaches in the Swedish classi- 
cal schools, as compared with schools of other types in 
the same country, has usually been interpreted as a 
direct result of the closer application to books and the 
somewhat longer study hours of the classical schools. 
This theory, however, does not satisfactorily explain 
the distribution of headaches in Russian schools as 
shown in the following table from Klilopine : — 



TABLE 


29 










Per cent with 


Type of school 


Number of pupils 


headaches 


Boys' schools — 








(a) Classical 




44,184 


8 
7.W 


(b) Modern language 




22,539 


(c) Technical 




2,228 


13.9 


Girls' schools 




44,029 


11.25 



The authors of the investigations quoted above are 
unanimous in placing the responsibility for headaches 
partly upon the school, and the relatively higher inci- 
dence which they have found in the upper grades and 
in schools with the most difficult programs bears out 
this claim. However, the investigations in Norway by 
Hoist in 1901 and by Magelssen in 1904 have given 
results not altogether in harmony with this theory (4) . 
Both these studies show about the usual incidence, 
varying from 10 to 23 per cent, but fail to show any 
increase in the higher grades to correspond with the 
increase in number of hours of school and home study. 
Magelssen even finds a steady decrease from the first 
to the fourth grade. This decrease was also more 
marked for severe and prolonged headaches than for 



284 THE HYGIENE OF THE SCHOOL CHILD 

the light and transitory. It should be noted, however, 
that the latter studies were by no means so extensive 
as the others. Moreover, Magelssen himself concludes 
that, although the school's responsibility for children's 
headaches has been exaggerated, school life neverthe- 
less favors the appearance of headaches in children who 
are predisposed to them. 

A careful study of the most recent and authoritative 
medical literature on this subject suggests that the 
underlying causes of headaches are poorly understood; 
" shrouded in darkness," as Magelssen puts it. In fact, 
headache is not only one malady, but many, since it 
arises from a large variety of causes. Hardly any organ 
of the body but may, when diseased, give rise to ahead- 
ache. As stated by Woods Hutchinson (3), "the head, 
in its vicarious sufferings, is continually doing fire- 
alarm duty for the other parts of the body." The signi- 
ficance of headaches depends strictly on the individual 
factors concerned and hardly lends itself to discussion 
in general terms. In most cases, however, it is con- 
nected with one or more of the following conditions : — 

(1) Anaemia. All the writers agree that there exists 
a close connection between headaches and an impov- 
erished condition of the blood, though of course the 
two are not always associated. Nearly all anaemic 
adolescent girls suffer occasional headaches, while 
those with good blood and habits of outdoor activity 
seldom do. 

(2) Reflex irritation. This is one of the most import- 
ant causes, and includes eye-strain, impacted or cari- 



THE HEADACHES OF SCHOOL CHILDREN 285 

ous teeth, adenoids, nasal catarrh, etc. Eye-strain 
is the most important of this group. 

(3) Toxic conditions of the blood due to constipa- 
tion, recent or approaching illness, excessive fatigue, 
etc. Of these, constipation and the accumulation of 
fatigue toxins due to habits of inactivity are the factors 
with which the school is most concerned. Constipa- 
tion ranks with eye-strain as one of the most frequent 
causes of headaches. 

(4) General nervous instability, due either to hered- 
itary or acquired defect of the central nervous system. 
This is one of the most fundamental factors, and one 
which is operative to greater or less degree in naarly all 
classes of headaches. Neither temporary anaemia, nor 
impacted teeth, nor eye-strain, nor all these together 
will necessarily be productive of headaches in the 
otherwise healthy child. But the child who is charac- 
terized by general weakness, growth deficiency, or 
nervous instability falls a victim to headaches from 
apparently trivial causes. An examination of the 
heredity of such a child usually brings to light an un- 
usual number of neurotic tendencies in the family 
stock: migraine, neurasthenia, hysteria, susceptibility 
to shock, etc. Gout and rheumatism are also frequently 
associated with the neurotic disorders. It is for this 
reason that headaches are here classed and treated 
with the general group designated as nervous defects, 
even though medical treatises for the most part have 
referred only migraine to strictly nervous causes. The 
newer developments in the functional aspects of psy- 



286 THE HYGIENE OF THE SCHOOL CHILD 

chopathology, represented by Freud, Jung, Ernest 
Jones, and others, are rendering the once rigid distinc- 
tion between nervous and non-nervous headaches 
more and more difficult to maintain. 

Migraine is a headache characterized by its excru- 
ciating severity and by the physical prostration which 
accompanies it, though it may not be as lasting or as 
frequent as is likely to be true of headaches of other 
types. It is often preceded by certain premonitory 
symptoms, such as slight dizziness, misty vision, diffi- 
cult language articulation, and aphasia. After a half- 
hour or so these symptoms subside and the pulsating 
throbs of headache begin. The child prefers to lie per- 
fectly quiet with head turned from the light. The face 
is haggard and the pulse weak. Nausea, sometimes with 
vomiting, is common. After a few hours the pain sub- 
sides, sleep comes on, and the patient finally awakes 
fully recovered, except, perhaps, for a slight feeling of 
weakness or apathy.^ With both boys and girls, nerv- 
ous headaches tend to recur periodically. The evi- 
dent hereditary kinship of migraine to other nervous 
diseases throws far more light upon its causes than does 
its occasional association with eye-strain or toxic con- 
ditions of the blood. At the same time, there is no doubt 
that both the frequency and the severity of migrain- 
ous attacks can to no small degree be controlled by a 
careful hygienic regimen, though not so completely as 
other types of headaches. 

^ See Leonard Guthrie, Functional Nervous Disorders of Child" 
hood, pp. 150-52. 



THE HEADACHES OF SCHOOL CHILDREN 287 

Prevention 

In whatever form the malady shows itself, the un- 
portant thing for teachers and school physicians to 
understand is that a headache means something. In- 
stead of treating the headache, as such, the underly- 
ing causes should be investigated. It is well, first, to 
look to the habits of life; second, to the condition of the 
eyes; and third, for other unfavorable physical condi- 
tions and indications of overpressure. Worry, insomnia, 
and gastro-intestinal disturbances act as both cause 
and effect. Plenty of exercise in the open air, baths, 
ample sleep, a well-selected diet, attention to adenoids, 
nasal catarrh, eye-strain, and defective teeth, coupled 
with a thoroughly hygienic school program, would 
probably enable all but the most neurotic constitu- 
tions to escape the affliction. Headaches are not made 
inevitable by a bad heredity. In the schools of Christi- 
ania, headaches decreased in frequency about 40 per 
cent between 1891 and 1901, a fact which Magelssen 
thinks is due entirely to the introduction of medical 
supervision, school lunches, and a considerably light- 
ened program. As long as 10 to 20 per cent of our 
children suffer from this defect, the school cannot es- 
cape the duty of using every available means to com- 
bat it. 

HEFERENCES 

*1. S. Briigelmann: Die Migrane, ihre Entstehung, ihr Wesen, etc. 
Wiesbaden, 1909, pp. 51. 

2. Leonard Guthrie: The Functional Nervous Disorders of Child- 
hood. 1909, pp. 149-54. 

3. Woods Hutchinson: Preventable Diseases. 1909, pp. 442. 
(Chapter xvii.) 



288 THE HYGIENE OF THE SCHOOL CHILD 

*4. A. Magelssen: "Ueber das Kopfweh, — hauptsachliche Mi- 
grane — an der Mittelschule." Inter. Mag. Sch, Hyg., vol. i, 
1905, pp. 285-301. 
5. B. K. Rachford: Neurotic Disorders of Childhood. 1905, pp. 
355-65. 



CHAPTER XVI 

PREVENTIVE MENTAL HYGIENE i 

I. THE NERVOUS CHILD 

The insane population of the United States amounts 
to about 200,000 persons. A few years ago most of 
these were children enrolled in the public schools, and 
we may well raise the question whether an educational 
regime specially adapted to their needs could ha^e pre- 
served any considerable proportion of them from their 
sad fate. 

Sanity is a relative term. Where one becomes in- 
sane, a dozen develop harmful idiosyncrasies, or a lack 
of that balance which characterizes the ej65cient, reli- 
able, and responsible person. Minor mental abnor- 
malities, far from being rare, are seen on every hand; 
excessive irritability, unbridled emotionalism, alcohol- 
ism, certain criminal tendencies, obsessions, unreason- 
able fears, absurd prejudices, neurasthenia, hysterical 
suggestibility, etc. Mental balance is the exception, 
not the rule. Disregarding the inevitable imperfec- 
tions and minor disharmonies of control, there are 
millions of people whose daily behavior does not justify 
a claim to average sanity. When our conceptions of 

^ The author is indebted to Dr. E. B. Huey for many valuable 
suggestions in the preparation of this chapter. 



290 THE HYGIENE OF THE SCHOOL CHILD 

the neuroses are sufficiently enlarged, they will include 
in the class of nervously afflicted a large proportion 
of the criminals, industrial failures, and other ineffi- 
cients. At least 5 per cent of our school children are 
neurotics in the sense that they are more than ordinar- 
ily predisposed to the development of mental "com- 
plexes" unfavorable to the healthy and coordinated 
functioning of intellect, emotions, and will. 

Some nervous disorders purely functional 

We are indebted to the functional point of view in 
modern psychiatry for opening up a new world of edu- 
cational principles and suggestions. As long as mental 
disorders were considered solely from the standpoint 
of disease, and explanations were sought purely in 
terms of pathological organic conditions, the certain 
tendency was to lose sight of border-line cases. From 
this standpoint people fell definitely into two classes: 
the sane and the mentally diseased. The concept of 
prophylaxis became narrowed to include only the 
means of avoiding outright insanity. Even this kind 
of prophylaxis, according to the fatalistic views which 
prevailed until recently regarding all mental disorders, 
had little room for influence. 

Although a pathological basis has been determined 
for certain forms of mental disorder, it is a matter 
of the greatest educational significance that for some 
insanities and for most of the minor disturbances of 
mental function no underlying nervous pathology has 
been established. Such defects are coming to be looked 



PREVENTIVE MENTAL HYGIENE 291 

upon as purely functional, by which is meant that 
they are the result of unfortunate emotional experi- 
ences, unhealthy associations of ideas, defective will- 
training, etc. 

Especially significant is the fact that the roots of 
most functional mental disorders have been traced 
back into the period of childhood. An initial mental 
deviation of slight extent may lead ultimately to in- 
sanity, hysteria, crime, suicide, or a life of wretched 
discontent and inefficiency. The balance and sanity 
of the adult are largely predetermined in the years of 
childhood. 

From the functional point of view, preventive 
mental hygiene thus becomes as broad as education 
itself. It becomes the duty of those charged with the 
education of the young to recognize the dangers in- 
cident to mental development, to identify the child of 
neuropathic tendency, and to throw about him the 
influences of training and environment which will 
direct him into the paths of normal thought and be- 
havior. It is necessary, therefore, to pass in review the 
most common symptoms by which the neurotic con- 
stitution may be recognized. 

Symptoms of nervous disorders 

It is understood, of course, that not all the symp- 
toms enumerated in the following pages are found in 
any single case. Nervousness, as some one has said, 
is not one disorder, but a whole cohort. It may assume 
any one of many forms, and the symptoms will vary 



292 THE HYGIENE OF THE SCHOOL CHILD 

accordingly. The symptoms listed here include nearly 
all of those commonly seen in neurotic persons. 

On the physical side the nervous child is likely to be 
restless, to lack inhibitory power, to be easily startled 
or shocked, and to suffer from muscular twitches or 
automatisms. Often there is a lack of control of the ac- 
cessory muscles, with stuttering, overmobility of the 
facial muscles, nervous fingering of objects, etc. The 
features may be tense, the step hurried and clumsy, 
the grasp insecure. Pencils, books, and papers are 
dropped, the feet are shuffled, and the like. The child 
becomes the despair of the teacher. When the arms 
are raised in the forward position the fingers either 
tremble or extend themselves with tense rigidity. In- 
coordinations may be present, so that, for example, 
the child cannot walk with a book balanced on the 
head. Indigestion is common, together with anaemia, 
deficient or freaky appetite, etc. Often the heartbeat 
is irregular or excitable. The eye accommodation may 
fatigue easily, causing the print to blur. Headaches are 
common. 

The most significant symptoms, however, are the 
emotional and volitional. The nervous child is apt to 
be unstable in its emotional life, easily turned from 
laughter to tears, quick to anger, irritable, peevish, etc. 
There is constant hunger for excitement, and distrac- 
tion is sought in variety of stimulation. The child is 
not happy without an array of playthings or occu- 
pations. Numberless idiosyncrasies may develop, in- 
volving habits of play, work, dress, eating, etc. The 



PREVENTIVE MENTAL HYGIENE 293 

eccentric child is always a nervous child. Sleep is usu- 
ally affected. The child has dijQBculty in getting to 
sleep, has to be tucked in several times, wakes easily, 
has night terrors, gets up peevish, etc. 

The life of the nervous child is often made wretched 
by haunting fears, — fear of the dark, of burglars, of 
impossible animals, of death, hell, the loss of father 
or mother, etc. Sometimes the fear is not specific, but 
is evident as a vague "anxiety state" which makes the 
child forever apprehensive. Nervous children are usu- 
ally oversensitive to the opinion of others, unable 
to endure blame, and constantly hungry for praise. 
Severity shatters them, but for the sake of appr^al or 
to surpass others they will work to the point of exhaus- 
tion. The sexual emotions may be prematurely or 
abnormally developed.^ 

Normal conduct, conceived as the suitable adapta- 
tion to concrete environment, involves the highest 
of human powers, and is the first to suffer when the 
nervous controls are weakened. The nervous child is 
hesitating, timid, vacillating, unable to cope with the 
real. More and more he falls back upon day-dreams, 
books, imaginative enjoyments, etc. He plays little, 
adjusts badly to other personalities, is seldom a leader. 
Not infrequently he is made an outcast by his fellow- 
pupils. Not being able either to mingle on equal terms 

^ While most nervous children show the type of symptoms given 
above, certain ones, on the other hand, are apathetic, listless, and 
indifferent. These limp, over-quiet, under-tense, and nervously defi- 
cient children are apt to be overlooked because they are facile and 
docile. 



294 THE HYGIENE OF THE SCHOOL CHILD 

with other children or to depend on himself, he clings 
to adults and becomes oldish and precocious. 

The feeling of weakness, distrust of self, low resist- 
ance to fatigue, inability to work under pressure, diffi- 
culty in deciding what to do next, are other volitional 
symptoms of the neurotic constitution. Work is al- 
lowed to drag along unfinished and appointments are 
not promptly met. Neurotics easily acquire the habit 
of tardiness. 

Absurd scruples, religiosity, or over-conscientiousness 
may appear. The child weeps from stepping on ants, 
considers it sinful to eat meat, suffers torments over 
imaginary sins, etc. There may be a foolish abhor- 
rence of dirt, so that the hands must be washed dozens 
of times a day. Sometimes the scruples concern dress, 
manners, eating, excretory processes, etc. 

From what has already been said, it is clear that 
the moral life is also involved, for morality is nothing 
but the appropriate issue of thought and emotion in 
conduct. The most common moral faults of nervous 
children are lack of self-control, outbreaks of tem- 
per, incorrigibility, stubbornness, sulking, egotism, 
lying, kleptomania, personal vices, etc.; in short, 
the faults that go with feelings of weakness and in- 
capacity. 

The outbreaks are not so much due to the over- 
powering strength of impulses as to the weakening of 
controls. Abnormal stubbornness, contrary to common 
opinion, does not indicate strength of will, but weakness 
and faulty adaptation. Lying is often a defense neuro- 



PREVENTIVE MENTAL HYGIENE 295 

sis. The undue persistence (i.e., beyond ten or twelve 
years) of the normal childish tendency to boastful, 
imaginative lies is distinctly pathological, and not 
infrequently masks a feeling of weakness, incapacity, 
inferiority, etc. Sometimes it is a mere symptom of 
abnormal egotism. Kleptomania is often an obsession, 
a fixed idea, involving the collecting instinct. The 
most common moral faults of the neurotic, however, 
are instability, unreliability, and weakness. 

Symptoms relating to intelligence are not as numer- 
ous or characteristic as the emotional and volitional 
symptoms. Nervous children are fully as likely to be 
bright as dull, but their intelligence is seldon^of the 
most practical sort. The imagination is likely to be 
overactive. There is often an abnormal preoccupation 
with books, language, and abstractions as contrasted 
with things. These traits give the impression of men- 
tal precocity. The child is hailed as a prodigy, paraded 
as a genius, etc., with unfortunate consequences for his 
later development. Some of the wonder-children are 
stupid in everything except their exhibition specialties. 

One-sided development is favored in the neurotic 
child because of the diflSculty of giving voluntary, 
or forced, attention. Mental association takes the path 
of least resistance. Extraordinary accumulations of 
information alternate with gaps of profound ignorance. 
Day-dreaming and intellectual indolence take the place 
of determined attack upon the varied intellectual 
problems set by the school or environment. Periods 
of intense intellectual activity may occasionally super- 



296 THE HYGIENE OF THE SCHOOL CHILD 

vene, followed by slumps that may be characterized 
as "twilight states." Comprehension is uneven. 

Suggestibility, often, is abnormal. The child imi- 
tates the peculiar gestures of those he admires. Stutter- 
ing and even choreiform movements are sometimes 
initiated in this way. The organization of their ideas 
may be unduly influenced by accidental stresses. In- 
stability characterizes the intellectual as well as the 
emotional and volitional life. The neurotic child is the 
creature of his environment.^ 

The picture may be made more clear by the follow- 
ing description of a concrete case : — 

Girl, aged 7. Weight and height normal for age. Bright 
and highly imaginative. Two years advanced in school. 
Speech, blustering, with hasty and indistinct articulation 
which months of daily drill failed to improve. Finical in her 
habits. Has an unconquerable preference for stimulating 
and highly seasoned foods, pickles, salt, spices, cakes, coffee, 
hot soups, etc. Seldom eats the more wholesome articles of 
food except under compulsion. Almost from babyhood has 
had an abnormal interest in dress. Plans for weeks ahead 
the apparel for set occasions. Absurdly preoccupied with 
ceremonies and symbolisms relating to birthday, Christmas, 
Easter, etc. All such occasions are planned for in the minut- 
est detail. Her life is pathologically subjective and intro- 
spective. Volatile, cries at slightest censure, fishes for praise. 
Is oversensitive to the good will of the teacher and over- 
works at school from emulation. Over-affectionate, yet 
imperious and hard to manage. Unreliable, "forgets" 
promises. Sleeps poorly, has nightmares, wakes easily and 
cannot get to sleep again for hours. Obsessive fears make 
her miserable as night approaches. She cannot go to sleep 

^ See Hysteria. 



PREVENTIVE MENTAL HYGIENE 297 

without a light in the room and some one beside the bed. 
The bed must be against the wall, the doors shut and locked, 
etc. She is tormented with religious and moral scruples. 
Worries if prayers are forgotten, and cannot bear the thought 
of missing Sunday School. Suffers from headaches, anaemia, 
and constipation. Gestures are awkward and exaggerated. 
Always fingering objects. Fumbles and drops things. 

Suggestions for observation ^ 

I. Disturbances of motor-control. 

Overmobility of facial muscles. 

Twitching of eyelids, face, or fingers. (Test control 
of fingers by having children close the eyes and 
sit with hands extended, palms down, on the 
desk.) % 

Spasmodic movements of any kind. 

Bad coordination. (See if child can walk with book 
balanced on the head.) 

Drops objects frequently from the hands. 

Jerky handwriting. 

Inability to sit still. (Ask children to sit still for 
five minutes.) 

Stuttering. 

Blustering, rapid speech. 

Nail-biting, chewing pencil, fumbling a button, etc. 

Bed-wetting. 

Frequent requests to go out. 
II. Emotional and moral disturbances. 

Irritability or bad temper. 

Laughs or cries at slight cause. 

Undue emotion of any sort. 

Extreme suggestibility. 

Excessive timidity or embarrassment. 

^ The writer is here indebted to Cornell's Health and Medical 
Inspection of School Children, pp. 333-34, and to Dr. E. B. Hoag. 



298 THE HYGIENE OF THE SCHOOL CHILD 

Misbehavior. 

Sex perversions. 

Perverted tastes. 

Moroseness, sullenness, or obstinacy. 

O ver-aff ectionateness . 

Undue sensitiveness to praise or blame. 

Over-conscientiousness. 

Heligiosity. 

Day-dreaming. 

Lying or stealing (if moral environment is good). 

Cruelty. 

Finical habits. 

Eccentricity or "queerness." 

Child an "outcast" among his fellows. 

Sleep disturbed (nightmares, tooth-grinding, sleep- 
walking, etc.). 

Morbid fears. 

Chronic uneasiness or apprehension. 
m. Indications of nervous exhaustion. 

Apathy. 

Dull eyes. ^:; 

Drooping shoulders. 

Slouching postures. 

Shuffling gait. 

Arms and hands droop when extended forward. 
IV. Associated physical conditions. 

Adenoids. 

Eye-strain. 

Headaches. 

Faintness or dizziness. 

High fatiguability. 

Poor nutrition. 



CHAPTER XVII 

PREVENTIVE MENTAL HYGIENE 
II. COMMON NEUROSES OF DEVELOPMENT 

Psychasthenia 

Accepting Janet's conception of psychasthenia, we 
may define the condition as one of chronic uneasiness 
and disquiet, with feelings of incompleteness. Obses- 
sions, impulsions, lack of certitude, anxiety, timidity, 
longing for moral support and comfort, meqtness, 
indecision, etc., are the most common symptoms. If 
extreme fatiguability is present as one of the main 
symptoms the condition is known as neurasthenia.^ 
The symptoms may include any or all of the long list 
given in the preceding pages as characteristic of the 
neurotic constitution. Visceral disturbances, disorders 

^ Psychasthenia and neurasthenia are variously defined by differ- 
ent authors. Janet states that they are "two manifestations of dif- 
ferent degree and gravity," of which "neurasthenia is the initial 
form." Neurasthenia, says Janet, is essentially "an organic enfeeble- 
ment" marked by bodily symptoms, such as weakness, trembling, 
digestive troubles, and the like. Visceral disturbances are especially 
common. In psychasthenia the disturbances present themselves 
more especially in the conscious mental life. "Psychasthenia is a 
depressive psycho- neurosis characterized by diminution of the func- 
tions which permit us to act on reality and to perceive the real, by 
the substitution of mental operations that are inferior and exagger- 
ated, under the form of doubts, of agitations, and of anxieties, and by 
obsessive ideas which express the preceding troubles and which them- 
selves express the same character." (Les Obsessions et la Psychas- 
thenic, vol. I, pp. 754-55.) 



300 THE HYGIENE OF THE SCHOOL CHILD 

of nutrition, headaches, insomnia, constipation, ver- 
tigo, muscular weakness, etc., are a few of the many- 
symptoms likely to be associated with it. 

Psychasthenia is common among adults, but is sel- 
dom met with among children. A considerable propor- 
tion of teachers are affected, probably 3 to 5 per cent. 
According to Ballet (1) it is most common among busi- 
ness men, teachers, and students, and least among 
laboring men, the clergy, farmers, and physicians. 
More women than men are subject to it. 

Until recently medical authorities endeavored to 
explain psychasthenia in terms of physical causation, 
such as chronic exhaustion of the central nervous sys- 
tem due to overwork, or a condition of auto-intoxi- 
cation resulting from infectious diseases, glandular 
disorders, etc. Adolescent overpressure was thought to 
play a great part. 

It is now generally believed that psychasthenia may 
be of functional origin, a result of the interplay be- 
tween a somewhat unstable heredity and certain ele- 
ments of an unsuitable training. Over-repression is one 
of these. The functional view is supported by the fact 
that a psychoanalytic search for the causes, followed 
by reeducation of the patient along the lines of his 
mental faults, often brings a cure. The methods of 
Christian Science, Yoja practice, etc., sometimes ac- 
complish this result in an unscientific way; the trained 
psychiatrist succeeds through his knowledge of under- 
lying psychological principles. 

From the functional point of view, childhood is the 



PREVENTIVE MENTAL HYGIENE 301 

critical period for those of psychasthenic tendency. A 
training which inculcates over-conscientiousness and 
scrupulosity, which destroys self-confidence and initi- 
ative, or fails to develop a rich fund of healthful, objec- 
tive interests, lays the foundation for the pathological 
timidity, indecision, weakness, anxieties, and morbid 
fears characteristic of psychasthenia. Interesting illus- 
trative cases are described by Dr. Williams (60). 

(1) A boy, reproved severely by his puritanical parents 
for jealousy of his little brother, developed chronic mental 
distress, the mania for touching things {delire de toucher)^ 
and was a slave to the apparently absurd impulse to lie down 
on his back several times when putting on his clothes. In- 
vestigation brought out the fact that these were childish 
devices for expiation for the sin of jealousy. 

(2) A girl of eight years was brought to Dr. Williams 
because of involuntary facial grimaces and foolish gestures, 
such as touching the floor before she stepped on it. The girl 
had been severely trained, particularly along the line of 
avoiding injury to others. Questioning revealed that the 
child had worried for fear her expired breath, which she had 
been taught was poisonous, might do injury to others. The 
facial grimaces were discovered to be kissing movements, 
since, from her childish way of thinking, kissing each breath 
of expired air would "make it well." The touching of wood, 
likewise, was the "healing touch" that would keep it from 
being hurt by her tread. 

(3) Affectionate girl with parents of cold, nagging dis- 
position, who did not permit in her any show of affection. 
The child developed insomnia, headache, dizziness, habits 
of crying, etc. Reform of the parents brought relief to the 
child. 

Williams concludes that the moral sanctions suit- 



302 THE HYGIENE OF THE SCHOOL CHILD 

able for adults may be decidedly injurious to children. 
Coupled with puritanical over-repression, they tend to 
develop obsessions and anxieties, the mania to com- 
pensate, to expiate, to make contracts with Fate, etc. 
Let us avoid moral over-pressure by not taking the 
faults of the child too seriously and by holding him to a 
standard of conduct commensurable with his imma- 
turity. 

Hysteria 

Hysteria is essentially an enfeeblement of mental 
control, of the synthesizing, organizing, and directive 
powers of the mind. This lowering of what Janet calls 
the "psychic tension" permits emotional shock or 
strain to start dissociation, or mental cleavage. Cer- 
tain thought-systems drop out of consciousness, or are 
banished because of their disagreeable emotional tone. 
Queer and inefficient "substitutions" then take the 
place of the lost thought-systems, the substitutions 
being themselves the symptoms of the disorder. 

The symptoms are marked by abnormal suggesti- 
bility, dominance of automatisms, dreamy states, etc., 
and may include all sorts of motor and sensory disturb- 
ances, such as convulsions, tremors, paralyses, vaso- 
motor and secretory disorders, anaesthesias, hyperses- 
thesias (under-sensitivity and over-sensitivity), etc. 
Pin-pricks in certain localities may not be felt. The 
visual field may be retracted in one or both eyes, and 
numerous other symptoms of similar nature may ap- 
pear without any real physical disability underlying 
them. The disorder is purely functional. 



PREVENTIVE MENTAL HYGIENE 303 

True hysteria does not often develop earlier than 15 
to 18 years, but authorities are agreed that the mental 
conditions which lead to the hysterical manifestations 
have their origin in the first fifteen years of life. Hys- 
teria is always predetermined in the school period or 
in the period immediately preceding school life. 

The characteristic trait of those hysterically in- 
clined is abnormal suggestibility, together with emo- 
tional instability. The "railroad-wreck" spine illus- 
trates very well the mental mechanism of one form of 
hysteria. A young woman is thrown from her seat in a 
collision of trains. She is picked up unable to walk 
and carried to the hospital. Although the most Careful 
diagnosis, including the radiograph,^ reveals no injury 
whatever to spine or hips, the patient may remain for 
months in a paralyzed Or semi-paralyzed condition. 
There may be no conscious intent to deceive or simu- 
late in order to secure damages, get sympathy, etc.; 
the case is due entirely to suggestion. Chorea, deaf- 
ness, speech defects, asthma, and many other disorders 
are sometimes of hysterical origin. It is, therefore, 
always a problem to distinguish true chorea, real 
organic deafness, etc., from their hysterical simula- 
tions. 

School epidemics of various kinds of psychical con- 
tagion have their origin in the hysterical predisposi- 
tion. Of several such epidemics described in the inter- 
esting study of Dr. Burnham (4) one or two may be 
quoted here. 

* X-ray pictures. 



304 THE HYGIENE OF THE SCHOOL CHILD 

(1) The Liegnitz epidemic. 

One of the earliest reported epidemics of this kind oc- 
curred in Gross-tinz, near Liegnitz, Germany, in 1892. The 
first case appeared on the 28th of June, when a ten-year-old 
girl, without apparent occasion, began all at once to tremble 
in her right hand and then gradually in the whole body, a 
condition which passed off in about half an hour without any 
further results. On the next day the trembling appeared in 
several other girls, and lasted from half an hour to an hour. 
Not the children sitting next, but those several seats away, 
were affected. The trembling returned regularly each day and 
began to last longer and longer, and the school instruction 
soon suffered because the girls who were attacked could not 
write. One day, at the beginning of July, one of the trem- 
bling girls was attacked with convulsions and fell under the 
seat. Although the teacher immediately removed this child 
from the class, several new cases of convulsions soon appeared 
among the healthy girls, and on the 19th of July the number 
of victims was twenty. During the period from the 14th to 
the 20th of July, the instruction was equally exciting for 
both teacher and pupils, and presented a noteworthy picture 
to the medical observer. On almost every seat were patients 
having convulsions of the whole body. The girls fell under 
the seats and had to be carried from the room by the boys, 
and the attacks continued for different periods of time be- 
tween a quarter of an hour and an hour, when they gradu- 
ally ceased. After the autumn vacation the attacks ceased 
and no fresh cases were reported. 

(2) In October, 1905, a thirteen-year-old girl in Meissen 
was attacked with a tremor or shaking of the hands. Soon 
other cases appeared, and although it was hoped that the 
trouble would disappear during the Christmas vacation, this 
did not happen, but in January and February the disease 
became epidemic, and by the 21st of February, 134 children 
were afflicted. The classes were then closed until the 14th of 



PREVENTIVE MENTAL HYGIENE 305 

March, and the parents were given advice in regard to the 
treatment of the children. In spite of this, the number in- 
creased. On the 20th of March, 237 children were suffering 
from the disorder. Then the number began to decrease, and 
on the 29th of March there were only 196 afflicted, and by 
the 17th of May the epidemic seems to have been at an end. 
The disease was caused by seeing a child who had it; and 
children from all classes, strong and weak, were attacked, 
especially the girls. The causal factor must have been psy- 
chic infection.^ 

Children should never be punished or blamed for 
such hysterical symptoms, nor should their attention 
be needlessly directed toward their disorder. There 
may be no conscious pretension on the child'^ part. 
The special class has been used to advantage in such 
epidemics to prevent the spread of the contagion, and 
soon brings about a cure of those already afflicted. 
The Basel special class of 1904, organized for this pur- 
pose, went on with the regular school work, and by 
means of suggestive treatment applied in the form of 
simple gymnastic exercises, warm lunches, etc., all the 
cases were speedily cured. 

Real hysteria is not extremely common, but the 
emotional instability and the hyper-suggestibility 
bordering on hysteria are not uncommon. To fixate 
the child's attention too intently upon matters of 
health, to over-stimulate the precocious, to permit day- 
dreaming to take the place of productive work, to 
destroy in any way the feeling of self-reliance and per- 

^ Epidemics of hysteria are of course extremely rare. They are 
instructive, however, because they illustrate the possible force of 
that psychic contagion which in milder form is known to every one. 



306 THE HYGIENE OF THE SCHOOL CHILD 

sonal independence, all help in the formation of char- 
acters that may become hysterical. To enter into the 
"league of silence" regarding sexual matters and to 
conceal from the child the knowledge of sex demanded 
by a normal curiosity leads to the acquisition of all 
kinds of false notions and to "modes of repressions 
and concealments of emotional states which may be- 
come the nuclei for hysterical manifestations in later 
life" (13). 

Dementia proBcox 

Dementia prsecox is one of the most interesting 
forms of insanity for several reasons. In the first place, 
it is extremely common, accounting for some 30 per 
cent of the total admissions to insane hospitals. In the 
second place, it does not attack the old or mentally 
decripit, but the youth, and quite frequently the youth 
of marked intellectual promise. In the third place, the 
newer studies of the disease show that it is probably 
due in most cases to definite, ascertainable functional 
disturbances of the individual's mental evolution, and 
that, if taken in hand early enough, it will yield to the 
right kind of educational treatment. In the fourth 
place, the methods which have been successfully used 
in its prevention and treatment throw a flood of light 
on preventive mental hygiene in general. The lesson it 
teaches forms a contribution of real value to the prob- 
lem of education for efficient living. 

Dementia prsecox is a form of adolescent insanity 
which usually involves fantastic day-dreaming, sexual 
imagination, brooding over disappointments, and (the 



PREVENTIVE MENTAL HYGIENE 307 

most central symptom) a discrepancy between thought 
and action. As described by JelKffe (26), it is most 
likely to develop in those "who are abnormally bril- 
liant, but whose lights are turned inward." The pa- 
tient may be gentle in disposition; of dreamy, lofty, 
exclusive, disdainful demeanor; conceited, egotistic, 
given to deep ruminations, and always unpractical. 
"There is a glorification of vague abstractions" 
coupled with "a constitutional aversion to deeds." As 
characterized by Dr. Meyer (40), it is essentially "a 
miscarriage of instincts through lack of balance"; a 
deterioration of habits "due to progressively faulty 
modes of behavior and action"; "a covering-upvather 
than a correction of harmful yearnings." In the classi- 
cal description of Dr. Meyer, "There develops an insid- 
ious tendency to substitute for an efficient way of meet- 
ing difficulties a superficial, moralizing self-deception, 
and an uncanny drift into many varieties of shal- 
low mysticism and metaphysical ponderings or into 
fantastic ideas which cannot possibly be put to the test 
of action. All this is at the expense of really fruitful 
activity, which tends to appear insignificant to the 
patient in comparison with what he regards as far 
loftier achievements. Thus there develops an ever- 
widening cleavage between mere thought-life and the 
life of actual application, such as would bring with it 
the corrections found in concrete experience. Then, 
under some strain which a normal person would be 
prepared for, a sufficiently weakened and sensitive 
individual will react with manifestations which con- 



308 THE HYGIENE OF THE SCHOOL CHILD 

stitute the disorders of the so-called * deterioration 
process,' or dementia prsecox. Unfinished or chronically 
sub-efficient action, a life apart from the wholesome 
influence of companionship and concrete test, and 
finally a progressive incongruity in meeting the inev- 
itably complex demands of the higher instincts — this 
is practically the formula for the deterioration process." 
The following are clinical descriptions of typical 
cases, the first from Dr. Meyer, the second from Dr. 
Hoch : — 

(1) She began school at seven years, was smart, and 
appUed herself well, but at the age of eleven she seemed to be 
failing, and was thought to be studying too hard. She grew 
thin, seemed nervous, and complained of headaches; at 
twelve she was in poor health. . . . [Later] She was disap- 
pointed at home, for some time dreamt of becoming a teacher, 
but soon sank into hypochondriacal ruminations, and fin- 
ally, at twenty-one, after useless surgical operations, passed 
into a confused religious excitement, followed by stupor, in 
which she sits inactive and irresponsive, with the top-heavy 
and yet empty notion of being good, of saving the world, etc. 

(2) The patient is said to have been retiring, modest, shy; 
had to be driven to play. The parents say that the other 
child they have is aggressive, while the patient is not; that 
the other looked out for herself, while the patient relied on 
others. She was always afraid she had not done things right. 
. . . When thirteen, she became inactive, lost interest, be- 
came dissatisfied with things, got rattled at school and could 
not do her work. Then followed vague talk about deep sub- 
jects, such as "Why does the universe exist .5^" and so on. 
By fifteen she was gravely deteriorated. 

The next few decades may witness the complete 



PREVENTIVE MENTAL HYGIENE 309 

demonstration that such cases can usually be saved by 
being taken early in hand and trained to more com- 
plete activity and appropriate self-objectification. 

But, as already indicated, the importance of this 
principle of the sanifying influence of wholesome ac- 
tivity does not lie merely in the insurance it offers 
against insanity. Inasmuch as sanity is purely a rela- 
tive term, the importance of activity and self-objecti- 
fication goes far beyond its prophylactic value as an 
insurance against admission to an insane hospital. In a 
sense no one is perfectly sane. Just as there are millions 
of physically inefficient persons who are in no immedi- 
ate danger of death, and relatively few who ar^erfect 
of body, so there are numberless people who are in no 
danger of trial for lunacy, but who, nevertheless, are 
decidedly below their best level of mental balance. 
Dementia prsecox has been mentioned at length only 
because it reveals, writ large, that which to a less de- 
gree is true of most of us. The causes which produce 
complete deterioration in the individual of nervous 
instability may, in the person of better hereditary 
endowment, result in nothing more serious than a tem- 
porary nervous breakdown, "a slump of relative inac- 
tivity," or some other manifestation tending to rob 
life of its zest and render success more difficult. 

In order to escape such dangers, children need to be 
taught to ** avail themselves of the power of the con- 
crete.*' School work should feed the instinct of work- 
manship instead of starving it. As Meyer states it, 
"If the school gave more opportunity for doing things. 



310 THE HYGIENE OF THE SCHOOL CHILD 

dreams of doing would be less tempting." It behooves 
us "to make doing just as attractive as knowing," and 
to explore ways and means of enlarging the child's 
opportunities for the accomplishment of simple, whole- 
some, and enjoyable things. Plays and games which 
demand quick decision and self-reliance are indispens- 
able to a well-balanced mental development. Good 
players seldom become "queer" or socially inefficient. 
We must find for each child the level where he can 
function successfully if we would have him escape the 
shocks of disappointment, the habits of failure, and the 
resulting inactivity, day-dreaming, vain wishing, and 
the chasm between thinking and doing. If we will only 
take pains to fit the tasks to the capacity, every child 
can be taught to do certain things well and to take 
pleasure in doing them. Nothing is more subversive of 
sanity than a regime of inactivity and repression which 
creates a smouldering volcano of sentiment and frothy 
desire. 

Chorea {St. Vitus's dance) 

In a majority of cases chorea is associated with rheu- 
matic affections of the joints, "growing-pains," etc., 
though in all probability it presupposes also the neu- 
rotic constitution. The onset often seems to be occa- 
sioned by overwork, excitement, shock, and the like, 
and it is certain that, notwithstanding the connection 
with rheumatism, a certain proportion of cases could 
be prevented by suitable mental hygiene. Rheumatic 
symptoms in children not characterized by nervous 
instability are not, as a rule, followed by chorea. 



PREVENTIVE MENTAL HYGIENE 311 

Chorea is by no means an uncommon disease, affect- 
ing probably about one child out of a hundred some- 
time during the school life. It seldom appears before 
the age of 6 and not often after 14. Of 2000 cases ana- 
lyzed by Starr 45 per cent began between 6 and 10, 38 
per cent between 11 and 15. It occurs more often in 
the spring months. Girls are affected much more often 
than boys, according to Still (48), in the ratio of about 
5 to 2. The choreic child is usually bright, often pre- 
cocious and of excitable temperament — exactly the 
child who is most likely to be spurred on to rapid 
school progress and who is most likely to be injured 
by it. % 

The duration of the disease is usually from six weeks 
to three months, though a few cases drag on with little 
change for years. Because of the connection with 
rheumatism the heart is very likely to be affected. 
Dr. Still found heart symptoms in 155 out of 250 cases. 
Many adults who suffer from organic heart disease 
are merely victims of a neglected rheumatic infection 
during childhood. On account of the danger of heart 
involvement, as well as for the needed mental rest, it is 
very important that chorea be diagnosed in its earliest 
stages, and that the child be taken from school at once 
and put to bed. Absolute rest in bed is always advis- 
able for a period of from three to six weeks, and school 
work should not be taken up for several months. Re- 
currences are very common, especially in the spring 
months, and all authorities are agreed that nothing is 
so likely to determine a fresh attack as the too early 



312 THE HYGIENE OF THE SCHOOL CHILD 

return to schooL An additional reason for keeping the 
child out of school until all symptoms have disap- 
peared is the danger of psychic contagion. Veritable 
school epidemics of chorea have been recorded. 

Every teacher, therefore, should know the symp- 
toms of beginning chorea. The disease generally ap- 
pears so gradually that the child is likely, to its great 
injury, to be allowed to continue in school for two 
or three weeks, or longer, after it has begun to de- 
velop. 

At first the child maybe considered unusually nerv- 
ous. It drops things, has difficulty in sitting still, is 
clumsy in eating or buttoning the clothes, has an awk- 
ward, shuffling, unsteady gait, and stumbles. Some- 
times the first symptoms are slight spasms of the facial 
muscles, twitching of the eye, grimaces, and the like. 
Later the movements become intensified, irregular, 
jerking, and almost constant except during sleep. In 
severe cases speech is almost impossible, and the child 
may be practically unable to walk or to handle fork or 
spoon in eating. The mental symptoms of chorea are 
often almost as characteristic as the physical. The 
child is irritable, emotional, capricious, inclined to 
worry, sleeps badly, has nightmares, headaches, and a 
poor appetite. Blood examinations nearly always show 
profound disturbances of nutrition.^ 

When fully developed, the disease is not easily mis- 
taken for any other nervous affection except habit- 

^ The rheumatic infection is thought to bring about the rapid 
destruction of red blood corpuscles. 



PREVENTIVE MENTAL HYGIENE 313 

spasm, and this distinction may usually be made with- 
out difficulty if it is remembered that habit-spasm 
is always quite definitely located in certain muscles, 
while the movements of chorea are irregular and more 
generally distributed. You can describe the movements 
of habit-spasm, get a definite picture of them, but you 
can seldom tell what twitchings or grimaces the choreic 
child will perform next. 

It is the early symptoms especially with which the 
teacher should try to familiarize herself, the slight 
awkwardness, twitchings, unrest, peevishness, excita- 
bility, thickness of the tongue, etc. As a rule the child 
is scolded or punished at home and at school fc^ a week 
or two after the disease is under headway. It is useless 
to expect the average parent to make the diagnosis in 
the early stages, but teachers with their larger oppor- 
tunities for observing children may learn to do so if 
they are at all observant. 

TicSy habit-spasms, etc. 

These are forms of spasmodic movements which 
shade into one another and are sometimes difficult to 
differentiate from chorea. Tics and habit-spasms in- 
volve an isolated twitching or contraction of any 
muscle or muscle-group, as of the face, tongue, neck, 
or organs of respiration, such as elevating the lip to 
meet the nose, sniffling, lightning-like blinks or nods, 
writhing, shrugging the shoulders, elevating the chin 
and stretching the neck, protruding the tongue, show- 
ing the teeth, emitting queer guttural noises, etc. The 



314 THE HYGIENE OF THE SCHOOL CHILD , 

movements may be confined to one muscle, or muscle- 
group, or there may be a whole repertoire of foolish- 
looking grimaces. One week the tongue may be 
chiefly concerned, next week the lips or eyebrows. 

The movements are automatic and involuntary. 
By extreme effort of will they may be suppressed for a 
little while, but are sure to reappear as soon as effort 
is relaxed; or if the tic is conquered in one location, it 
reappears elsewhere. To punish, nag, or scold children 
for their habit-spasms is sheer cruelty. As well combat 
stuttering with the rod. The defect is always aggra- 
vated by unsympathetic treatment. Rewards and 
praise for successful control are much more eflficacious. 
Daily practice in self-control before a mirror, motor 
exercises involving arms, neck, muscles of respiration, 
etc., have been used to advantage. 

But tics, habit-spasms, etc., are now believed to 
be usually of psychical origin. Anaemia, over-pressure, 
and reflex irritations, such as intestinal parasites, de- 
fective teeth, a sore on the face, etc., may be the occa- 
sion of their appearance, but are seldom, if ever, the 
true cause. They are more often associated with emo- 
tional repression, obsessions, phobias, and other evi- 
dences of functional instability, and, as Williams has 
shown, are usually curable by suggestion and the 
methods of psycho-analysis. Sometimes they disappear 
of themselves, especially if the child is not punished or 
scolded. In other cases, if not properly treated, they 
become fixed by habit almost beyond eradication. 
Strong emotion, worry, and overwork aggravate them. 



PREVENTIVE MENTAL HYGIENE 315 

Here, as everywhere else, prevention is better than 
cure, and much easier. Marked and intractable cases 
should be taken from school because of the danger of 
psychical contagion. 

Nervous automatisms differ from tics and habit- 
spasms in being less spasmodic and less confined to 
particular muscles. All sorts of aimless movements are 
included here, such as shuffling the feet, fingering pencil, 
button, the hair, etc., pulling at the ear, rubbing the 
nose, biting the lips or nails, stretching the fingers, 
tapping, turning, thumping the knees, and the like. 
To a greater or less degree automatisms are almost 
universal, and unless excessive need not occasion con- 
cern. Lindley (32) found that the "accessory " muscles 
are more often involved than the "fundamental," par- 
ticularly in the upper grades; that there is little differ- 
ence between the sexes; that they are greatly increased 
by intense mental effort; and that they are especially 
characteristic of fatigue states. Automatisms indicate 
defective control rather than excess of energy, and are 
aggravated by the school's repression of "fundamental " 
movements. The important point for the teacher to 
understand is that the nervous restlessness of the child 
who never sits still is not due to willfulness. It is better 
to send such a child out to play, or to think up some 
errand for him to do, than to nag or punish. If the 
restlessness is chronic and extreme, thorough medical 
examination should be secured. 



316 THE HYGIENE OF THE SCHOOL CHILD 

Epileptic school children 

True epilepsy is probably always due to some 
hereditary defect of the central nervous system, and 
is seldom curable. Usually, though not always, it 
involves progressive mental deterioration leading to a 
marked degree of feeble-mindedness. Tests of several 
hundred epileptic children at the New Jersey Epilep- 
tic Village at Skillman (56) showed an average mental 
retardation of three to four years at the age of 10 or 
11, increasing to seven or eight years by the age of 15. 
Such cases really belong in separate schools or insti- 
tutions where they can have the medical supervision 
and the special educational treatment suited to their 
needs. If the fits are of such a character, or if they 
occur at such times, as to disturb the work of the 
school, the epileptic child should under no circum- 
stances be permitted to attend classes with normal 
children. 

Some cases of what appears to be epilepsy are due 
to bodily disturbances, such as auto-intoxications, eye- 
strain, decayed teeth, intestinal parasites, nasal 
growths, etc. 

There is a mental equivalent of epilepsy, so-called 
"psychic epilepsy," the nature of which all teachers 
should be acquainted with. Psychic epilepsy is a kind 
of mental explosion, "brain-storm," during which the 
patient may make an attack or do and say all sorts of 
unaccustomed things. The period may last from a few 
minutes to several hours, and is followed by a normal 
state in which the patient remembers little or nothing 



PREVENTIVE MENTAL HYGIENE 317 

of his unusual acts. Swift (51) cites the case of a school 
girl eight years old who, "while standing in line with 
her classmates, suddenly broke away from the others 
and ran around in a circle three or four times, then 
looked confused, giggled a little, and became quiet. 
W^hen repi:imanded by the teacher she insisted that she 
did not know what had happened." In this case the 
attacks became frequent and were succeeded by true 
epileptic seizures. 

Dr. Healy, who has for several years been engaged 
in a psychological and medical study of juvenile of- 
fenders in the Psychopathic Institute connected with 
the juvenile courts of Chicago, found that mc^e than 
7 per cent of 700 third-time offenders were victims of 
psychic epilepsy. Sometime, perhaps, we shall know 
enough to substitute medical care and education in 
place of the punishment usually meted out to such 
unfortunates. Likewise the teacher would do well to 
take a sympathetic attitude toward the school child, 
by no means rare, who is subject to sudden explosions 
of anger or irritability. The following instance came 
under the observation of the writer : — 

Boy of 14, mentally retarded (in the third grade), usually 
good-natured and quite inoffensive, became enraged one day 
at school over some trifling incident and struck one of the 
older girls senseless. The teacher, a man, considered the act 
as purely volitional, and beat the boy unmercifully. 



' CHAPTER XVIII 

PREVENTIVE MENTAL HYGIENE 
III. THE EDUCATION OF NERVOUS CHILDREN 

Most authorities on mental diseases believe that the 
appearance of any severe neurosis (other than a certain 
few due to infectious diseases or toxins causing definite 
anatomical lesions) always denotes an inherent psy- 
chopathic tendency in the subject. Even granting 
this, however, we are not forced to take the fatalistic 
point of view. The unfavorable heredity is, after all, 
only the inheritance of a tendency. Whether the evil 
made possible by heredity materializes probably de- 
pends in a majority of cases upon what we may call 
accidental factors of environment. 

The accidental factors may be divided into two 
groups: (1) Preventable physical abnormalities which 
favor the development of nervous conditions. Among 
these are adenoids, eye-strain, intestinal worms, mal- 
nutrition, impacted or decaying teeth, the toxins re- 
sulting from overwork or the incomplete elimination 
of body wastes, lack of exercise, fresh air, sleep, etc. 
(2) Faulty education, particularly of the emotional 
and volitional functions. 

The necessity of attending to the factors named in 
the first group is admitted in all schemes of psychopro- 
phylaxis, while the importance of the pedagogical 
factor is almost as universally neglected. • 



PREVENTIVE MENTAL HYGIENE 319 

Faulty education as related to nervous disorders 

Nevertheless, modern researches in functional psy- 
chopathology are constantly making it evident that 
the misery suffered by neurotics is due very largely 
to faulty education, using this term in the broadest 
sense. "Alas," said Goethe, in Wilhelm Meister, "how 
much there is in education, in our social institutions, 
to prepare us and our children for insanity." 

In our classification of people as nervous, weak, 
balanced, self-confident, selfish, magnanimous, etc., 
we tend to lose sight of the conditions and experiences 
which have made them so. Most of us look upon im- 
perfections as intentional products of a perverted will, 
forgetting that the will itself, even character, is but 
the composite resultant of an infinite number of in- 
dividual acts and experiences. Nothing happens in 
mental cosmogony, not even the perverted will. What 
we are going to think or do, how we are going to feel, 
depends upon what we have thought, done, and felt. 
Character is "an epitome of the past and a forecast 
of the future" (46). The only reason things seem to 
happen in mentation is that many of the connecting 
links are hidden below the threshold of consciousness. 
The study of the subconscious, however, has at last 
succeeded in bringing to light submerged, associative 
elements which explain many of these apparent happen- 
ings. Law and order are thus taking the place of what 
before was psychological chaos. 



320 THE HYGIENE OF THE SCHOOL CHILD 

Suppressed feelings 

In the most literal sense, everything that is experi- 
enced is conserved. Not that it can be recalled, any 
moment, by an act of the will; but conserved in the 
sense that it will remain functionally active as a deter- 
miner of future mentation. Thus Freud demonstrates 
that when in childhood a disagreeable emotion is sup- 
pressed, carrying with it into apparent oblivion a host 
of associated memories, the disagreeable emotion and 
its suppressed associates are by no means annihilated, 
but may reappear in adult life as phobias, obsessions, 
hysteria, etc., whose origin is not suspected by the 
patient and can only be brought to light by the methods 
of psycho-analysis.^ 

Nervous states, therefore, if we can accept the func- 
tional explanation of the Freudians, may have as their 
basis unassimilable experiences, experiences which 
because of their painful feeling tone have been sup- 
pressed as by a mental censorship. 

But suppression, as already indicated, is not equiva- 
lent to annihilation. The suppressed elements remain 
as "disturbers of the peace," giving rise to inner men- 
tal conflicts, to anxieties, stuttering, obsessions, hysteri- 
cal symptoms, and the like. During sleep, when the 
faculty of censorship is weakest, they obtrude them- 
selves in the form of night terrors, dreams involving 

1 For an exposition and criticism of psycho-analysis see the 
article by Harry W. Chase, " Psycho- Analysis and the Unconscious," 
Pedagogical Seminary, vol. xvii, pp. 281-327. Also other references 
at the close of this chapter, especially reference 3. ^ 



PREVENTIVE MENTAL HYGIENE 321 

wish fulfillment, etc. Even in waking life they may- 
exert a constant pull sufficiently strong to determine 
the direction which life activities shall take. It is a 
wise man who knows the real sources of his likes, his 
aversions, his ideals, and his prejudices. 

The puritanical suppression of the play instinct and 
of the spirit of adventure in the young may rid us of 
certain troublesome pranks and inconveniences, but 
we are coming to believe that it creates a harvest of 
vice, crime, and neuroses. Whatever else play may 
mean, Aristotle's conception of it as a catharsis is 
essentially correct. The child whose conduct is molded 
too closely by adult moral standards, whose devilish 
spirit of adventure is denied all the customary outlets, 
is likely some day to overflow with the accumulated 
"cussedness" of years. Mental hygiene demands that 
the larks and pranks of boyhood be not too severely 
frowned upon. 

Prevention of morbid fears 

There is danger in all forms of mental irreconcilia- 
tions which lead to suppression. The condition result- 
ing is one of imperfect mental unity, or in extreme cases 
even double personality. Conflicts arise, entailing 
fears, the feeling of inadequacy, etc. An important 
function of education, as Plato observed, is to teach 
children to fear aright, which means to free them from 
the fears that are unreasonable, imaginary, or the out- 
growth of weakness. Fear is the evil genius of most 
nervous people. The fear of insomnia keeps them 



THE HYGIENE OF THE SCHOOL CHILD 

awake; the fear of exhaustion induces in them the 
chronic feehng of fatigue; the fear of not succeeding 
makes hopeless failures of them; the fear of their own 
Tmpulses makes them slaves of each momentary whim. 
Over-conscientiousness, which comes as a rule from 
self -distrust, does not betoken moral strength, but self- 
distrust, and is a poor guaranty of right conduct. 
*'Keyed-up prepossessedness," sometimes seen in one 
who sets about doing something with all his might, 
has in it an element of fear and has been experimentally 
proved to be unfavorable to success.^ The school 
should assist parents to "discover and to remove the 
overgrowths of fear" which attach themselves para- 
sitically to the lives of so many children, and to pre- 
vent the development of irrational fears, prejudices, 
and aversions. 

There is danger, however, that the extreme applica- 
tions made of this principle by Christian Scientists will 
blind us to its essential truth. The best way to com- 
bat fear is by reason and by the gradual habituation 
to courageous acts. Once convince a man that two 
hours of sleep, more or less, will not matter much, he 
will cease to fear insomnia and will sleep. If the child 
fears the dark, let him become accustomed, little by 
little, to venturing alone in the dark, and each suc- 
cessful venture will add to his courage : only it is nec- 
essary to go slowly to avoid shock. Once thoroughly 
convince the stutterer, by speech drills or otherwise, 

1 See W. F. Book: The Psychology of Skill, with Special Reference 
io Typewriting. 1908, pp. 136/., 



PREVENTIVE MENTAL HYGIENE 323 

that it is possible for him to speak without tripping, 
and he is placed well on the way to recovery. By a 
little experience of success, appropriately arranged for 
by a thoughtful teacher or parent, the child who is 
dijQfident and distrustful of his powers is released from 
his paralysis of will and inspired with confidence. 

Even when the difficulties which beset the fearful 
and timid are not wholly imaginary, the patients can 
be taught to face them honestly and to make the best 
of a bad situation. The neurasthenic has been fitly 
described as "the person who runs away from a diffi- 
culty into the refuge of a nervous breakdown." It is 
especially destructive of mental integrity for Jhe child 
to be always shielded from the consequences of his own 
acts; whence the sanifying influence of plays and games 
in which error brings its certain penalty and skill its 
quick reward. By a scheme of treatment thoroughly 
enough reversed from its true order the bravest child 
may be made into a coward. Conversely, the most 
timid may be made to tingle with confidence and 
courage. 

The value of social experience 

Social experience is an indispensable corrective for 
the introspective tendencies of nervous children. 
Because of self-distrust, morbid suspicion, egotism, or 
"queerness," they adjust imperfectly to social environ- 
ment, and are likely to withdraw into themselves, to 
contemplate life rather than to live it. In this way the 
abnormality is aggravated. The social outcast, whether 
he be one from choice or otherwise, usually lacks the 



324 THE HYGIENE OF THE SCHOOL CHILD 

finer elements of mental balance. The best corrective 
of character development is to have to face the natural 
social reactions which our conduct calls forth from 
others. " Es formet ein Talent sich in der Stille; sich 
ein Karakter in dem Strom der Welt."^ 

Methods of discipline 

The hygiene of discipline plays no small part in 
psycho-prophylaxis. Nagging, arbitrary, or tyrannical 
parents and teachers either destroy the child's will or 
make it rebellious. The unstable and whimsical child 
is often but the victim of a nervous mother. The 
tyrannical, domineering father need not wonder when 
his son develops into a psychasthenic, weak, vacillating, 
and dependent upon others for guidance. 

Training in self-reliance and self-control 

Parental over-solicitude and excessive affection 
likewise tend to make the child dependent and to de- 
velop a mania for sympathy, the hesoin d'etre aime.^ 
The love bonds of infancy should normally dissolve as 
the child reaches maturity and be replaced by a tie 
of somewhat different nature. When this does not 
occur, when the relation of child to parent retains its 
infa^ntile quality, the foundation is laid for a life of 
weakness and nervous invalidism. How to free the 
child from the circle of parental influence, without en- 
dangering the mellower filial attachment.which should 

1 Talent is nourished in solitude ; character, by a life of action. 

2 Abnormal craving for love. 



PREVENTIVE MENTAL HYGIENE 325 

succeed it, is one of the important problems of child- 
training. 

Self-reliance does not grow up out of habits of de- 
pendence, nor does steadfastness develop out of unin- 
hibited impulses. If we would free children from bond- 
age to their whims, we must train them to concentrate, 
to attend. The power of concentration is not a faculty, 
but rather the whole volitional attitude toward one's 
work, a function which enters into all of one's intel- 
lectual activities. It cannot be profitably trained by 
set exercises. What one has of it represents the total 
effect of the countless individual strokes of attention 
which one habitually gives. If these are alleged to 
be brief, aimless, or ineffectual, the injury so wrought 
cannot be corrected by a few normal exercises. Short- 
cut processes and pedagogical dosage can no more take 
the place of real education than patent medicines can 
replace the hygiene of physical development. In its 
play and in its work the child should, therefore, be 
encouraged to concentrate instead of being interrupted 
and dragged from one exercise to another. 

The extreme suggestibility which marks the hysteria 
psychosis is best combated by a training which fosters, 
without overworking, the power of inhibition. As 
Williams well says, let the child "be taught not to 
strike, not to follow, not to jeer, not to give in, even 
though others do so." Let him *' learn to take pride in 
being his own man, and not a puppet in the hands of 
others" (61). The culture of rationality also helps, for 
the hysterical is first and last uncritical. Whims and 



326 THE HYGIENE OF THE SCHOOL CHILD 

shallow impulsiveness do not thrive in the light of 
reason. Hysteria will be less common when education, 
from the kindergarten to the university, has more of 
the scientific background. Irrational prejudices can 
be combated by the same means. 

Cultivating efficiency 

Since habits are so much more persistent than is 
usually believed, there is special danger in the slump, 
intellectual or moral. The habits of peevish selfishness 
and fretfulness which are favored by a temporary ill- 
ness, with its bodily weakness, sympathetic nursing, 
and friendly solicitude, sometimes remain and poison 
all the rest of life. When children are not kept to their 
best level of scholarship they suffer an intellectual 
slump. Herein lies the great danger of making school 
work too easy. By holding every child to the lock-step 
of regular school performance, genius is effectually 
starved. The child with real ability is enslaved by 
"habits of inferiority" to his own best self. By dint of 
repeating things which are already known, or by being 
kept over-long at what is easily acquired, the mind 
becomes prematurely arrested. Curiosity is deadened 
and all the higher intellectual processes stunted. Har- 
ris, James, and Sidis have dwelt with emphasis on this 
important principle of education. 

Perhaps all of us have reserves of energy which we 
habitually fail to use and rich intellectual possibilities 
which we have failed to realize. The gates to these 
treasures are closed and sealed by the low opinion we 



PREVENTIVE MENTAL HYGIENE 327 

entertain of ourselves, by the discouragement and self- 
distrust incident to failure, and by other inhibitions or 
repressions. As a means of tapping the hidden treas- 
ures of power, James instances the dynamogenic effect 
of ideals, religion, patriotism, critical experiences, etc.; 
Sidis, the loosening of the inhibitory stresses by sug- 
gestion, by hypnoidization, or by otherwise convinc- 
ing the subject of the reality of his unused powers. 
"What the psychasthenic lacks mainly is the conviction 
of strength, not strength itself. 

Failure and success may indicate ability or they 
maybe the mere products of habit. That a majority of 
children fail of promotion once or oftener during their 
school life is one of the sad facts in our present scheme 
of education. Still more deplorable and costly, how- 
ever, is the failure of the talented few to go through 
school at the high level of intellectual performance 
possible to them. 

The sanifying effects of work 

The healthful influence of work has already been 
mentioned. The "instinct of workmanship" is one of 
the most generic of human motives, and when given 
a suitable outlet is one of the most sanifying. Espe- 
cially to be emphasized is the wholesome effect of 
objective interests and employments as an antidote 
to morbid self -analysis and one-sided imagination. 

Vocational guidance thus becomes an indispensable 
agent in preventive mental hygiene. There is no hope 
for the neurotic individual who is not successfully 



328 THE HYGIENE OF THE SCHOOL CHILD 

engaged in useful and interesting work. Hysteria is 
preeminently a disease of the unemployed, or the aim- 
lessly employed. Work which is interesting and fruit- 
ful so engages and practices the synthesizing powers 
of will, so unifies the personality, that disagreeable 
and submerged experiences have no chance to produce 
their effects of mental disintegration. The moral as 
well as the industrial efficiency of the world would be 
easily doubled if each individual were doing the work 
for which he is best adapted. 

Danger of shock 

It is a matter of common observation that neurotic 
disturbances are frequently ushered in by a shock, 
such as accident, sudden grief, fright, disappointment, 
etc. A woman may become insane after the death of 
her child, the school girl may develop chorea or stut- 
tering immediately after a fright. In such cases the 
grief or fright should not be regarded as the sole cause, 
but rather as the occasion for bringing forth what is 
already latent and near the surface. Shocks of grief, 
pain, fright, etc., do not start neuroses with every one. 
Nevertheless strong emotions suddenly induced are 
likely to produce injury and should as far as possible be 
avoided. The child's life should be one of fairly even 
tenor, at least until character and personality have had 
time to set. 

Many other principles of preventive mental hygiene 
could be listed and illustrated, but perhaps enough has 



PREVENTIVE MENTAL HYGIENE 829 

been said to show that, in the main, the principles 
involved are those of right education generally. The 
same may be said for the methods of psychotherapy, or 
mental cure, which are coming to rely more and more 
upon the method of reeducation. By following the 
strands of a neurosis back to its starting-point, back 
to the shock, or fear, or mental conflict which gave it 
birth, the fault in mental development may be cor- 
rected. The fears may be rationalized, the conflicts 
aired, so to speak, and brought to an understanding. 
Timidity may be educated out and replaced by confi- 
dence, hope, and the habit of success. But the process 
of re education' is slow and its issue sometimes dc^btful 
even when guided by the competent psycho-patholo- 
gist. Moreover, the latter is rarely available; there 
are not more than a few dozen in the entire country. It 
is easier and more effective to manage the work of 
education in such a way that reeducation will become 
less frequently necessary. All of the school's activities 
will ultimately be judged by the contribution they 
make to preventive mental hygiene in the broad sense. 

Children's sorrows 

To many people the sorrows of children are but fool- 
ish tears; their deepest griefs, humiliations, and disap- 
pointments seem but transitory affairs. Nothing could 
be further from the truth. Children's emotions are 
more compelling than our own; their sorrows are the 
most real there are. The child lives in the present, and 
his griefs, unlike those of men and women, are little 



330 THE HYGIENE OF THE SCHOOL CHILD 

mitigated by the memory of former joys or by the 
hope of others yet to come. 

All of this and much more relating to the tragedies 
of childhood is painfully depicted in the recent litera- 
ture on children's suicides. These seem to be on the 
increase in most civilized countries, and to show a 
tendency to occur lower and lower in the age scale. 
If the figures for France and Germany hold for the 
United States, it is probable that the annual number 
of suicides of children under 17 years of age amounts to 
about 500, and that the total number under 21 years 
exceeds 2000. 

Eulenberg's analysis of 1117 cases in Germany indi- 
cates that over one third of all were caused wholly or 
in part by the school. The causes most often named 
in this connection are fear of punishment, failure of 
promotion, unjust treatment, mental overwork, etc. 
Even when the school is not the fundamental cause of 
the school child's suicide, it is often blamable for failure 
to recognize the morbid mental condition and to sur- 
round the child with the appropriate counteracting 
influences.^ 

Special schools for nervous children 

In closing this chapter mention should be made of 
the rural school homes (Landerziehungsheim) , which are 
becoming popular in Germany for nervous or other- 
wise troublesome children. ^ Such schools have their 

^ For a discussion of this entire subject see reference 53, where the 
author has set forth the statistics and summarized the causes. 
^ See, especially, references 33 and 54 at the close of this chapter. 



PREVENTIVE MENTAL HYGIENE 331 

gardens and fields to cultivate, parks, swimming-pools, 
athletic fields, and endless opportunity for outdoor 
living, country tramps, etc. They are usually con- 
ducted on the cottage plan, and are provided with 
medical and dental supervision and treatment. The 
study program is somewhat shorter than that of the 
usual public school, sports and manual occupations 
have larger scope, and discipline is more natural, and 
confined principally to inculcation of the essentials 
of right conduct. The social spirit of cooperation and 
mutual helpfulness is fostered. The instructors are 
comrades and leaders rather than teachers in the ordi- 
nary sense. ^ 

The rural school home is especially desirable for 
the child whose home environment is faulty and for 
children of neuropathic tendency. Besides providing 
the ideal hygienic environment, it has a special ad- 
vantage in the fact that it can order the entire life of 
the child as long as he is in attendance. Too often 
the good that is daily wrought by the ordinary day 
school is undone before the following day by the evils 
of home life or by uncontrolled street associations. 
Although we cannot hope to have enough rural school 
homes for more than a few of the children who would 
profit from the treatment, they stand in many respects 
as an admirable model pointing the way to needed and 
possible reforms in the conduct of education every- 
where. 



332 THE HYGIENE OF THE SCHOOL CHILD 



SELECTED REFERENCES 

(Only those references having immediate bearing upon preventive 
mental hygiene in relation to education are included in this list. 
See also references to chapters xix to xxi.) 

1. Gilbert Ballet: Neurasthenia. 1908, pp. 407. 

2. Bayerthal: " The Work of -the School Doctor and Prophylactic 
Measures in Case of Nervous and Mental Disease." Inter. Mag. 
Sch. Eyg., 1912, pp. 513-16. 

3. A. A. Brill: Psychoanalysis: Its Theories and Practical Applica- 
tion. 1912, pp. 337. 

4. W. H. Burnham: "European Investigations in School Hygi- 
ene." Ped. Sem., 1910, pp. 525-33. 

*5. T. Clouston: The Hygiene of Mind. 1909, pp. 284. 
6. T. Clouston: Neuroses of Development. 1891, pp. 138. (Chiefly 
of historical value.) 

*7. Dannemann, Schober u. Schulze: EncyMopadisches Handbuch 
der Heilpddagogik. Halle, 1911, pp. 1974. (Inclusive and au- 
thoritative.) 
8. Dirks: "Der Tic im Kindersalter u. seine erziehliche Behand- 
lung." Zt. f. Kinderforsch., vol. xiii, pp. 257-67, and 290- 
97. 

*9. John E. Donley: "Psychotherapy and Reeducation." Jour. 
Ahn. Psych., 1911, pp. 1-10. 

10. Paul Dubois: "Conception psychologique de I'origine des 
psychopathies." Arch, de Psych., vol. x, 1910-11, pp. 47-70. 

11. Georg. Flatau: "Zur Psychologic der nervosen Kinder." Zt.f. 
Pad. Psych., 1907, pp. 445-57. 

*12. A. Forel: Nervous and Mental Hygiene. 1907, pp. 343. 
13. S. I. Franz: "Hysteria." In Monroe's Encyclopedia of Educa- 
tion, 1912, vol. Ill, p. 365. 

*14. S. Freud: Selected Papers on Hysteria and Other Neuroses, 
Translated by Brill. No. 4 of Nerv. and Men. Dis. Monog. Series. 

15. S. Freud: The Interpretation of Dreams. Translated by Brill. 
1913, pp. 500. 

16. W. L. Gard: "Some Neurological and Psychological Aspects of 
Shock." Ped. Sem., 1908. 

*17. Leonard B. Guthrie: Functional Nervous Disorders of Childhood. 

1909, pp. 300. 
18. W. T. Harris: "A Study of Arrested Development in Children 

as produced by Injudicious School Methods." Education, vol. 

XX, pp. 453-66. 
*19. Th. Heller: Grundniss der Heilpddagogik. 1904, pp. 366. (See 

especially pp. 272-331.) 
*20. Dr. W. Hellpach: "Die Hysteric u. d. moderne Schule." 

Inter. Mag. Sch. Hyg., 1905, pp. 222-52. 

21. Leo Hirschlaff: "Zur Gesundheitspflege des Nervensy stems." 
Zt. f. Pad. Psych., 1903, pp. 298-322. 

22. August Hoch: "Some of the Mental Mechanisms in Dementia 



PREVENTIVE MENTAL HYGIENE 333 

Prsecox." Jour. Abn. Psych., December, 1910, and January, 
1911. 
23. L. E. Holt: Diseases of Infancy and Childhood. 1912. (See 
contents; especially "Chorea.") 
*24. P. Janet: Les nevroses. 1910, pp. 397. 

25. P. Janet: The Major Symptoms of Hysteria. 1908. 
*26. S. E. Jelliffe: "Signs of Pre-dementia Prsecox; their Signifi- 
cance and Pedagogical Prophylaxis." Am. Jour. Med. Sci., 

1907, 157-82. 

*27. Ernest Jones: "Psychoanalysis and Education." Jour. Ed. 
Psych., 1910, pp. 4-97-520, and 1912, pp. 241-56. 

28. Ernest Jones: "The Psychopathology of Everyday Life." 
Am. Jour. Psych., 1911, pp. 477-527. 

29. C. Jung: "Psychology of Dementia Prascox." Translated by 
Brill. Jour, of Nerv. and Men. Dis. Monog. Series, 1909. 

30. Aug. Lemaitre: La vie mentale de V adolescent et ses anomalies. 

1910, pp. 240. 

31. D. F. Lincoln: Sanity of Mind. 1901, pp. 177. (See contents.) 

32. E. H. Lindley: "A Preliminary Study of Some of the Motor 
Phenomena of Mental Effort." Am. Jour. Psych., vol. vii, 
1895-96, pp. 491-517. 

33. Bruno Maennel: "Ein Erziehungsheim f. nervose Kinder." 
Inter. Mag. Sch. Hyg., 1910, pp. 324-29. 

34. Mathieu: "Neurasthenic et dyspepsie cliez les jeunes gens." 
Inter. Mag. Sch. Hijg., 1905, pp. 252-59. 

'35. H&axjM.a,ud&\ey: Pathology of Mind. 1880. (See especially pp. 

82-225.) 
36. Meige u. Feindel: Les tics et leur traitemenf. Paris, 1902. 
*37. Adolf Meyer: "The Dynamic Interpretation of Dementia 

Prsecox." ^Am. Jour. Psych., 1910, pp. 385-403. 
38. Adolf Meyer: "The Nature and Conception of Dementia 

Prsecox." Jour. Abn. Psych., December, January, 1910-11, 

pp. 274-85. 
*39. Adolf Meyer: "Analysis of the Neurotic Constitution." Am. 

Jour. Psych., 1903, pp. 354-67. 
*40. Adolf Meyer: "What do Histories of Cases of Insanity teach 

us concerning Preventive Mental Hygiene.?" Psych. Clinic, 

1908, pp. 89-101. 

41. C. Pascal: La demence precoce. Paris, 1911, pp. 300. (Empha- 
sizes educational aspects.) 
*42. O. Pfister: "Psychoanalysis and Child Study." School Hygiene, 

1911, pp. 366-74, and 432-42. 

43. Philippe and Boncour: "Apropos de I'examen medicop^da- 
gogique des ecoliers epileptiques." Inter. Mag. Sch. Hyg., 1905, 
pp. 259-70. 

44. Carl Polotzky: "Nervose Schuler." Zt. f. Schulges., 1911, pp. 
28-32. 

45. Morton Prince: "The Psychological Principles and Field of 
Psychotherapy." In Psychotherapeutics, 1910, pp. 11-46. 
Boston, R. G. Badger. 



334 THE HYGIENE OF THE SCHOOL CHILD 

*46. James P. Putnam: "Relation of Character Formation to 

Psychotherapy." In Psychotherapeutics, 1910, pp. 185-204. 

Boston, R. G. Badger. 
47. Boris Sidis: "The Psychotherapeutic Value of the Hypnoi- 

dal State." In Psychotherapeutics, 1910, pp. 119-44. Boston, 

R. G. Badger. 
*48. G. F. Still: Common Disorders and Diseases of Childhood. 1910. 

(See contents; especially "Chorea.") 

49. Spitzner: " Anzeichen beginnender Nervositat," Zt.f. Schulges., 
1903, pp. 395 /. 

50. W. P. Sp rattling: Epilepsy and its Treatment. 1904. 
*51. E. J. Swift: Mind in the Making. 1908, pp. 116-69. 

52. E. W. Taylor: "Simple Explanation and Reeducation as a 
Therapeutic Method." In Psychotherapeutics, 1910, pp. 25-85. 
Boston, R. G. Badger. 

53. Lewis M. Terman: "The Tragedies of Childhood" (children's 
suicides). The Forum, January, 1913, pp. 41-46. 

54. J. Triiper: Das Erziehungsheim u. Jungendsanatorium auf der 
Sophienhohe bei Jena. pp. 84. 

55. H. Vogt: Die Epilepsie im Kindesalter. Berlin, 1910, pp. 225. 
5Q. 3. E. W. Wallin: Experimental Studies of Mental Defectives 

(epileptics). 1912, pp. 154. 
57. Francis Warner: The Study of Children. 1898, pp. 264. (See 
especially chapters iv to vi.) 
*58. Tom Williams: " Psychoprophylaxis in Childhood." /owr. 24&n. 
Psych., 1909, vol. iv, pp. 181-99. Same in Psychotherapeutics, 
1910, pp. 161-81. Boston, R. G. Badger. 

59. Tom Williams: "The Genesis of Hysterical States in Childhood 
and their Relation to Fears and Obsessions." Med. Record, 
August 6, 1910. 

60. Tom Williams: "Cases of Juvenile Psychasthenia." Am. Jour. 
Med. Sci., December, 1912, pp. 865-74. 

*61. Tom Williams: "Nervousness and Education." Proc. Cong. 
Am. Sch. Hyg. Assoc, 1910, pp. 105-12. 

62. Dr. K. Wendenburg: "Ueber Chorea infectuosa u. Chorea 
hysterica." Monatschriftf, psychiat. u. Neur., 1910, pp. 232-68. 

63. H. Zbinden: "Conception psychologique du nervosisme." 
Arch, de Psych., vol. v, 1905-06, pp. 185-244. 

64. Th. Ziehen: Die Erkennung der psychopathischen Konstitution 
u. d. offentliche Fiirsorge f. psychopathisch veranlagte Kinder. 
Berhn, 1912, pp. 34. 



CHAPTER XIX 

SPEECH DEFECTS AND THE HYGIENE OF THE VOICE* 

Stuttering as a handicap 

The stuttering child presents a tragedy to which a 
majority of teachers and parents are strangely blind. 
At home the onset of the disease is a signal for impa- 
tience and reproof on the part of the parents. They 
often interrupt the child's speech with scolding or with 
peremptory orders to cease stuttering. School entrance 
does not mend the situation, but is itself a new crisis. 
The child notes with humiliation the looks and smiles 
provoked by his speech efforts. The teacher herself, 
if not exceptional, is prone sooner or later to lose pa- 
tience and to upbraid the unfortunate in the pres- 
ence of his fellows. She may accuse him of carelessness, 
or neglect to call on him for a recitation, and may even 
discuss his defect with other children in his presence. 
The trouble is, of course, aggravated. Every speech 
sound which offers the slightest difficulty becomes the 
focus for a stubborn phobia. These difficult sounds 
are more and more slurred over in fear. The very 
thought of having to attempt them may throw the 
whole vocal and respiratory mechanism into a panic. 

Though equal to other children in intelligence, the 

* For some of the material in this chapter the author is indebted 
to Dr. Hudson-Makuen, of Philadelphia, and Dr. E. W. Scripture, 
of New York City. 



336 THE HYGIENE OF THE SCHOOL CHILD 

stutterer, as Conradi's statistics prove (4), is likely to 
fail in classwork and to become retarded. The repe- 
tition of stale school work deadens interest with dis- 
gust. The child receives a training in failure. On the 
playground he encounters jests, badinage, and some- 
times ridicule. In the shop and on the street grown 
men amuse themselves at his expense. The victim's 
whole existence is poisoned. The more sensitive stut- 
terer comes to prefer silence to ridicule. He retires into 
himself, and as a result often becomes ill-tempered, 
hypochondriac, suspicious of others, or disagreeable. 
Lifelong moral suffering and permanent defects of 
character may be the issue. If the speech does not 
become normal, the vocational outlook is altogether 
unpromising. There is no place for the stutterer in 
law, medicine, the ministry, teaching, or many lines of 
business. Even marriage, on terms of social equality, 
is made difficult. 

The incidence of speech defects 

When we add to these considerations the fact that 
the number of stutterers exceeds the combined num- 
ber of deaf, blind, and insane (for whom all civilized 
governments have acknowledged the duty of making 
liberal provision), and when we remember further that 
a large majority of speech defects could be readily and 
inexpensively cured, the usual apathy assumes almost 
the aspect of cruelty. 

The incidence of speech defects in school children 
has been investigated by Westergaard and Lindberg 



SPEECH DEFECTS 



337 



in Denmark, by Von Sarbo in Hungary, by Rouma in 
Belgium, and by Conradi in the United States. The 
following table shows the most important findings of 
these investigations : — 







TABLE 


30 






Country 


Source of 
data 


Number of 
children 


Per cent 

with 
speech 
defects 


Per cent 
stutter- 
ing 


Name of 
investigator 


Denmark 
Denmark 

Hungary 

Belgium 
United 
States 


( Country 
( Cities 
( Cities and 
( Towns 
Cities 

Cities 


34,000 

212,000 

85,000 

231,000 
14,235 

87,440 


2.2 

11.5 

2.46 


.61 
.9 

.74 

1.02 
1.4 

.87 


Westergaard 
> Lindberg 

Von Sarbo 
Rouma 

Conradi 



If Conradi's statistics, which were collected in Mil- 
waukee, Cleveland, Louisville, Albany, Springfield, 
and Kansas City, are representative for the United 
States, then our school population contains about 
a half-million children with speech defects, nearly 
200,000 of whom are stutterers. 

All the authorities agree that speech defects are 
much more common with boys than with girls, the 
ratio usually being about 3 to 1. The following expla- 
nations, none altogether satisfactory, have been sug- 
gested by various writers to account for this superi- 
ority of girls: (1) The greater amount of language 
correction and instruction which girls receive as a 
result of their more intimate relations with the mother 
during childhood. (2) The relatively quiet and unex- 
citing mode of life to which girls are accustomed. 



338 THE HYGIENE OF THE SCHOOL CHILD 

(3) The preponderance of the costal type of breathing 
with girls. (4) The innate superiority of the girls in 
grace and accuracy of physical movement in general, 
seen also in their superiority over boys in writing, 
drawing, and other hand-work, and in the smaller 
amount of left-handedness. (5) The phylogenetic 
explanation that the domestic life which woman has 
led since the most primitive times has given her oppor- 
tunity for more continuous practice of the speech 
function than has been the case with man. Observa- 
tion (4) is probably a correct one, but leaves the funda- 
mental difference in the physical dexterity of the sexes 
unexplained . The phy logen e tic explanation need hardly 
be taken seriously. 

The terminology of speech defects is poorly defined 
in the English language. The main defects, how- 
ever, are two in number, designated in German as 
"Stammeln" and *'Stottern"; in French as "blesite" 
and *' begaiement." Both the English terms "stut- 
tering" and "stammering" correspond to the Ger- 
man "Stottern" and the French " begaiement," but 
"Stammeln" and "blesite" have no exact equivalent 
in our language. "Lisping" is coming slowly into use 
as the technical equivalent of the latter terms, but in 
popular language is usually restricted to that defect 
which consists in the substitution of the th sound for 

s or 2. 

Lisping 

Lisping is the most common speech defect, especially 
in the lower grades and the pre-school period. It 



SPEECH DEFECTS 



339 



includes the inability to pronounce certain letters or 
combinations of letters, and the tendency to omission, 
transposition, substitution, or slurring-over of sounds. 
It is found to greater or less degree in the speech of all 
young children and constitutes the most characteristic 
feature of *'baby talk." It may be considered abnor- 
mal only when it % * 
noticeably persists 
beyond the age of 
5 or 6 years. The 
frequency, as we 
should naturally 
expect, decreases 
rapidly in the up- 
per grades of the 
school. 

The accompany- 
ing chart from 
Rouma (22) shows 
for boys and girls 
separately the cradei 
gradual decrease in 
the percentage of 
lisping during the 
first six grades. The investigation included 15,846 
children. 

The undue persistence of lisping may be due: (1) to 
lack of practice in the proper use of the articulatory 
organs due to bad models in the child's language envi- 
ronment; (2) to weakness of the auditory center; (3) to 



13 
12 
11 
10 
9 
8 

i 
1 

6 

5 

4 

3 

2 

1 



\ 


y 








\ 


/ 












V 










V 
















^^x 






\ 




■'^ 




-A 


\ 


\ 






'% 










"f 










\ 


•~-.^___ 












\ 


SI 


UTTERl 


MG ^ 




\ 


_^ 


©oii^ 




tf"^ 


\ 


^' 




^"■■••. 


y 


\ 



II 



.III 



IV 



^■m 



FIG. 22 

Percentage of children lisping or stuttering in the 

first six grades. (After Rouma.) 



340 THE HYGIENE OF THE SCHOOL CHILD 

incomplete development of the speech organs; (4) to 
anatomical abnormalities of teeth, lips, tongue, jaws, 
soft or hard palate, nasal or pharyngeal cavities, etc.; 
or (5) to a general deficiency of the motor centers. The 
above factors may be operative in different combina- 
tions, and only a careful clinical study of the individual 
child will indicate the treatment necessary for a cure. 
Some of the lighter cases seem to be due either to a 
failure accurately to discriminate speech sounds, or 
else to carelessness or haste in their reproduction. 

Teachers meet all degrees of lisping, ranging from a 
mild lisp to the most complicated substitutions, omis- 
sions, and transpositions. Extremes of the latter, 
known as "idioglossia," may bear so little resemblance 
to the mother tongue as to be mistaken for an entirely 
original language.^ 

Stuttering 

Stuttering, or stammering, is the spasmodic repeti- 
tion of the initial sound of a word or syllable. The 
speech mechanism employs three sets of muscles: 
those of (1) respiration, (2) vocalization, and (3) artic- 
ulation. All of these must function together in the 
most delicate coordination if normal speech is to be 
produced. The incoordination of stuttering involves a 
cessation or interference of the respiratory movements, 
together with excessive innervation of the vocal mus- 
cles and a spasmodic contraction of the articulatory 

* For an interesting description of idioglossia the reader is 
referred to chapter xxi, reference 8. 



SPEECH DEFECTS S41 

muscles. The excessive innervation, or hyperphonia, 
is perhaps the chief feature. 

Stuttering is by far the most important of the speech 
defects and deserves a more extended treatment than 
is here possible. Unlike lisping, its frequency increases 
from grade to grade, at least up to the age of 10 or 11 
years. Rouma found an increase of 200 per cent from 
the first to the fourth grade (22). From the investiga- 
tions of Denhart, Sikorsky, Mygind, and Oltuszewski,^ 
it appears that a large proportion of the cases of stut- 
tering are contracted before the age of 6 years and 
nearly all the remainder before the age of 14. 

The results of Oltuszewski for age of onset a^e typi- 
cal. Of 535 cases reported by him, 7 began at 2 years, 
50 at 3, 67 at 4, 64 at 5, 47 at 6, 32 at 7, 39 at 8, 16 at 9, 
24 at 10, 6 at 11, 6 at twelve, 7 at 13, 2 at 14, and a total 
of only 6 from 14 to 21 years. The lower grades are, 
therefore, the most crucial as regards the development 
of the disease, though the onset of puberty frequently 
brings about the aggravation of cases which already 

exist. 

Causes of stuttering 

The influences causing or predisposing to stuttering 
may be grouped into six classes : — 

(1) The reflex, including adenoids, enlarged tonsils, 
defective teeth, etc. Of these, adenoids are the most 
important and are found with from 35 to 40 per cent of 
all stutterers. Dr. Bresgen thinks that nasal or pharyn- 
geal obstructions are at the bottom of nearly all speech 
^ Cited by Conradi, reference 3. 



342 THE HYGIENE OF THE SCHOOL CHILD 

defects. He thinks that, besides offering resistance to 
the sound waves, such obstructions render less easy 
the use of the muscles which are called into activity for 
phonation and articulation. This brings other muscles 
into requisition and leads to faulty coordination. 

(2) General weakness, including low muscular tone 
due to malnutrition, illness, overwork, etc. The 
anaemic are especially subject to the defect. Of 
Mygind's 200 cases, 18 followed acute illnesses, — 
measles, scarlet fever, pneumonia, whooping-cough, 
diphtheria, and mumps, named in order of frequency. 
School overpressure, worry, deprivation from fresh 
air, and insufficient exercise are often unmistakable 
factors. 

(3) Psychical causes, including shock, imitation, 
morbid fear, hysteria, etc. Baginsky and GutzmauD 
think that imitation is the most common cause of 
stuttering. One case is cited where a teacher with 
60 pupils had one stuttering pupil at the beginning of 
the school year and five at the end. A severe shock, 
such as a blow on the head or other physical injury, 
sometimes produces temporary speechlessness fol- 
lowed by stuttering. Agonizing fright may act in the 
same manner. Out of 535 cases analyzed by Sikorski, 
23 are attributed to fright, 47 to injury, and 30 to 
imitation. The influence of imitation can, of course, 
never be weighed with absolute accuracy because of 
the difficulty of ruling out all other possible factors. 

(4) Heredity. All are agreed that heredity plays a 
large part, a majority of investigators assigning it first 



SPEECH DEFECTS 343 

rank. Coen finds evidence of inheritance with 26§ per 
cent, Mygind with 42 per cent, Altuszuski with 45 per 
cent, Sikorski with 73 per cent, and Arndt with 77j 
per cent. The last mentioned authors have used the 
term "heredity" in a very broad sense, including 
evidence of all kinds of neurotic diseases in even dis- 
tant branches of the family. Among Mygind's 200 
cases, 84 were found who had a total of 124 stuttering 
relatives. Of the latter, 62 sustained the relation of 
brother or sister to the patients. Out of the 200, 32 had 
a total of 36 relatives who had suffered epilepsy or 
other convulsions. Of the 200 cases 58 had relatives to 
the number of 73 who had suffered "nervou^iiess," 
neurasthenia, hysteria, or nervous headache (migraine). 
Even when the immediate causes are especially promi- 
nent (fright, physical injury, illness, worry, fatigue, 
imitation, etc.), probably in most cases these operate 
in conjunction with a neuropathic constitution. 

The kinship of speech defects to other neuroses is 
also indicated by the fact that they are excessively 
prevalent among retarded and mentally defective chil- 
dren. Rouma found lisping about twice as frequent 
and stuttering about three times as frequent among 
the retarded as among normals, while feeble-minded 
children showed about seven times the normal fre- 
quency for stuttering. Miss Town's study of the 
language development of 135 imbeciles showed that 
only 14.7 per cent of the low-grade cases were entirely 
free from lisping or stuttering, 38 per cent of the 
middle grade, and 45 per cent of the high grade (26). 



344 THE HYGIENE OF THE SCHOOL CHILD x 

(5) Pedagogical maltreatment, such as ill-advised 
phonic drills and other faulty methods employed in 
the teaching of elementary reading. No statistics are 
available on this point, although it is one that has 
been repeatedly urged. Dr. A. Melville Bell and Dr. 
Hartwell have charged the schools with being the 
"breeding-ground of the stuttering habit," and have 
laid the blame largely on "misguided methods of 
instruction in reading and speaking." As pointed out 
by Huey,^ prevalent methods in phonics and in teach- 
ing to pronounce and to read aloud call the child's 
attention too much to the "how" of utterance and 
tend to produce a "mouth consciousness " which in- 
terferes with a process which was meant to function 
automatically. The coordination once established, the 
further consciousness stays away from the process the 
better. Its intervention produces nervousness, awk- 
wardness, and embarrassment, and is likely to balk 
the coordination completely. Work in phonics need 
not be excluded from elementary instruction, but it 
should be limited to well-regulated drill for the cor- 
rection of defective speech and to the necessary asso- 
ciation in the child's mind of certain of the more diflS- 
cult sounds with their language equivalents. 

The influence of the nagging, sarcastic teacher is 
still more serious. The cause of stuttering is as much 
psychical as physical, and often has its roots in a mor- 
bid fear, or speech timidity, produced by the teacher's 
severity. Rapid-fire questioning, compulsory answers, 
1 Psychology and Pedagogy of Reading, p. 598. 



SPEECH DEFECTS 345 

overpressure, and the like, are other school factors in 
the manufacture of speech defects. 

(6) Interference with normal left-handedness. Al- 
though it has long been believed that training left- 
handed children to the use of the right hand is likely 
to produce disturbances of the motor mechanism of 
speech, it remained for the painstaking investigation of 
Ballard (2) to establish the point beyond controversy. 

Three separate studies were made by Ballard. The 
first was by means of a questionnaire addressed to the 
teachers of 13,189 London children. Of these children, 
12,644, or about 97 per cent, were dextrals (i.e., right- 
handed) ; while the remaining 545, or 3 per ceni^ were 
sinistrals (left-handed by preference). Of the 545 
normally left-handed children, 399 had been required 
to learn to write with the right hand. These Ballard 
calls "dextro-sinistrals." The proportion of stutter- 
ing children among the pure sinistrals (left-handed 
children who were permitted to write with the left 
hand), was 1.1 per cent; among the dextro-sinistrals, 
it was 4.3 per cent. Requiring left-handed children to 
use the right hand thus multiplied the number of 
stutterers in this group by almost four. 

Ballard's second study of the relation between 
dextro-sinistrality and speech defects concerned 944 
mentally defective children. Of the 882 dextrals, 14, 
or 1.6 per cent, were stutterers; of the dextro-sinistrals, 
nearly 20 per cent. In this case, therefore, training in 
right-handedness multiplied the chances of stuttering 
by twelve. 



346 THE HYGIENE OF THE SCHOOL CHILD 

The third study was still more decisive. In this, 
Ballard made personal examinations of all the sinis- 
trals (322 in number) found among 11,939 children, 
8 to 14 years of age. Of the 322, 271 had been required 
to write with the right hand. Of these, 46 stuttered at 
the time and 24 had stuttered previously and recov- 
ered, or 25.8 per cent in all. Of the 51 sinistrals who 
had been permitted to use the left hand, not one stut- 
tered. The proportion of stutterers among dextro- 
sinistrals was, in this investigation, about eighteen 
times as great as among pure dextrals. 

Accepting the latter figures as the basis for our com- 
putation, it would appear that not far from one third 
to one half of the stuttering among London school 
children is produced in the effort to make right- 
handed children out of those who are normally left- 
handed. At least we are justified in concluding that 
the attempt to do this increases many times the lia- 
bility of stuttering. 

The physiological mechanism responsible for the 
relation between "handedness" and speech control is 
not sufficiently understood to warrant a discussion of 
the various explanatory theories which have been 
advanced. The fact that the relationship exists is 
sufficient for practical purposes. Left-handed children 
should remain left-handed, for writing at least. The 
slight advantages which would accrue from a change 
are entirely outweighed by the dangers to speech. 

In passing, it is interesting to note that left-handed- 
ness is twice as common among boys as among girls. 



SPEECH DEFECTS 347 

and since, therefore, an absolutely larger number of left- 
handed boys than left-handed girls are made to write 
with the right hand, this may account in part for the 
sex differences among stutterers. 

Whether other motor activities have the same effect 
as writing is not certainly known. Ballard believes, 
however, that the chief danger lies in the attempt to 
change the handwriting. 

The treatment of stuttering 

In whatever way stuttering has been caused, it is 
curable in at least nine cases out of ten. The work in 
foreign countries has demonstrated this abuncj^ntly. 
The fact that a few stutterers recover spontaneously 
has contributed to the neglect of curative treatment. 
To adopt the waiting policy with stuttering is no more 
justifiable than the omission of open-air treatment of 
tuberculosis. Stuttering, like bad grammar, tends, if 
persisted in, to become confirmed. 

Unfortunately, the treatment of stuttering is almost 
completely monopolized by quacks. Each "stutter 
specialist" boasts a secret, sometimes copyrighted, 
method. Outrageous prices are charged for a kind of 
treatment which is anything but scientific, and which, 
while curing some cases, leaves others in a worse con- 
dition than before. 

What could the school do for stuttering children? 
The admirable study reported by G. Rouma (23) sum- 
marizing the educational efforts in behalf of stutterers 
in European schools, affords an authoritative answer 



348 THE HYGIENE OF THE SCHOOL CHILD 

to this question. For many years the larger cities 
of Germany, Austria, Switzerland, and some other 
European countries have conducted special schools 
for the benefit of stutterers. Several types of such 
schools may be distinguished : — 

(1) The school vacation colony. ZUrich, for ex- 
ample, conducted such a school in 1899. The school, 
which was attended by 21 children, met daily in a for- 
est near the city. The morning hours were devoted to 
language exercises, breathing lessons, etc., while the 
afternoon was given over to games, tramps, and other 
forms of physical recreation. Though the school lasted 
only three weeks, several were cured and all were 
improved. Since then, Zurich has conducted an all- 
summer school for stutterers with a daily session of 
three hours. In the summer of 1902-03 the school 
was attended by 194 children. At the close of vaca- 
tion, 146 were entirely cured and all the others except 
two were improved. This type of school is especially 
valuable, for the reason that the stuttering child is 
so often weak, nervous, ansemic, and in need of 
general physical upbuilding. 

(2) After-school lessons. This is the type of school 
most in vogue at present in the countries of Europe. 
The exercises last about an hour each day, and are 
given by a teacher who has had special training for the 
work. The method usually commends itself to the 
school authorities because it does not interfere with 
the pupil's regular school lessons, but it is open to 
criticism in that it comes at a period when the patient 



SPEECH DEFECTS 349 

is already fatigued. Moreover, it interferes with the 
recreation and exercise so much needed by most stut- 
terers. Still another disadvantage is that when the 
treatment is made such an incidental matter, it does 
not always enlist the enthusiasm and voluntary effort 
so necessary in overcoming the defect. 

(3) Treatment within school hours. This is the 
method which has been employed in Berlin since 1901, 
and throughout Hungary. Like the special classes of 
type (2), these also meet daily, usually for one hour, 
and are ordinarily limited to a maximum of twelve 
pupils. Practically all the stuttering children in the 
cities of Hungary are treated in this way. 

In Berlin, Brussels, and Buda-Pesth, schools of 
orthophonies are conducted every year for the purpose 
of training teachers in the art of curing speech defects. 
Hungary has over two hundred teachers equipped for 
the educational treatment of stutterers. These are 
nearly always regular teachers who receive an addi- 
tional salary for the special work and are excused from 
a part of their other teaching duties. 

(4) A few European cities have established all-day 
special schools for stutterers. These, in the opinion 
of Rouma, are the ideal kind, because they allow a 
more thorough treatment than is possible by any 
other procedure. All the work of such a school can be 
adapted to the special needs of the patients, and the 
personal relations of teacher and pupil have time to 
become firmly established. Schools of this type recog- 
nize that stuttering is not merely a defect of speech, 



350 THE HYGIENE OF THE SCHOOL CHILD 

but that it involves usually an extended zone of nerv- 
ous defectiveness. They are often not feasible, how- 
ever, except in the more thickly populated cities, for 
the reason that it is necessary for some of the pupils to 
travel long distances to attend them. Another objec- 
tion sometimes made to this method of treatment is 
that removal of the stuttering child from association 
with normal children is likely to accentuate his con- 
sciousness of defect and in this way retard recovery. 
In actual practice, segregation does not seem to have 
this effect. Instead, in the opportunity it gives for 
emulation and class spirit, together with the release it 
affords from the atmosphere of criticism which so often 
oppresses the stuttering child when taught with 
normals, the special all-day class has distinct and im- 
portant advantages. 

Schools of all the types above mentioned are remark- 
ably successful. As a rule, recovery is complete within 
four or five months, and only rarely does a case prove 
entirely intractable. When a relapse occurs, as some- 
times happens, the child is given a second course of 
treatment, or even a third if necessary. Because stut- 
terers are likely to be misunderstood, badgered, and 
otherwise nervously maltreated at home, it has been 
found helpful to furnish parents with a pamphlet of 
instructions and to urge in personal conferences that 
they adopt an encouraging and sympathetic attitude 
toward the child. The ignorance of parents is one of 
the sad features of the situation. Sometimes they 
inveigh against the treatment, call it useless, a waste 



SPEECH DEFECTS 351 

of time, etc. Others consider it an unjustifiable inter- 
ference with the ways of Providence, who, they think, 
furnished the child with a thick tongue and meant for 
it to stutter. 

Treatment is most successful where each case is 
recognized as a special problem. Since the defect does 
not always arise from the same cause, it does not 
always need the same treatment. Extensive informa- 
tion is gathered and recorded regarding each child. 
This includes age, class, school progress, mental condi- 
tion, condition of nose, throat, ears, teeth, vital capac- 
ity, motor ability, evil sex habits, age at which walk- 
ing and speech were learned,^ age of dentition, record 
of illnesses suffered, condition of nutrition, ana com- 
plete data regarding all nervous troubles both in the 
child and his immediate relatives. 

Methods used in the treatment of stuttering 

A minute description of the methods employed in 
the treatment of speech defects would carry us beyond 
the scope of the present chapter. These will be found 
in the German works of Gutzmann and Liebmann, and 
in the American volume by Scripture. 

No one form of treatment has been generally agreed 
upon. Any method, to be successful, must be based 
upon a scientific understanding of the essential nature 
of the defect. The usual methods employed in the 
American private schools for stutterers are coined out 

1 The stuttering child often has a history of retardation in one or 
both of these functions. 



352 THE HYGIENE OF THE SCHOOL CHILD . 

of truth and fraud in the proportion of about one to 
nine. To use the illustration given by Dr. Hudson- 
Makuen (12) : — 

A stammerer is told to nod his head whenever he speaks, 
and because this procedure happens in this particular case 
to divert his attention sufficiently long to enable him to 
speak freely for a time, the quack thinks he has made a 
discovery, and immediately evolves a theory and establishes 
an institute with a secret method which consists solely in 
nodding the head in unison with the natural speech. Another 
advises beating time with the forefinger or thumb, or with 
the hand or foot during the process of speaking, and each of 
these schemes has been dignified as a "method" which is 
dispensed for a consideration under bonds of secrecy. There 
is even now a separate and distinct method which charac- 
terizes nearly every school and teacher engaged in the work, 
and these methods in many instances amount to little more 
than tricks. 

The partial success of such methods is due to the 
fact that the stutterer's trouble is to a great degree a 
mental one, — "a mental tic," as one writer has char- 
acterized it. The child stutters because he fears he will 
stutter. It is quite essential that the patient's self- 
confidence be aroused. He must forget that it is any 
longer possible for him to stutter. Appropriate speech 
exercises, proceeding very slowly from the easiest to 
the more diflBcult, and adapted to suit the needs of the 
individual case, gradually overcome timidity and dis- 
sipate the language obsessions. As stated by Makuen 
(13):- 

If he has weak will power, we must show him how to 



SPEECH DEFECTS 353 

strengthen it. If he lacks the faculty of attention or con- 
centration, we must show him how to acquire it. If he has 
grown morbidly introspective and self-conscious, he must 
be shown how to overcome this condition. If he is sufifering 
from fixed ideas and obsessions, if he has become neuras- 
thenic or psychasthenic, as many of them have, he must be 
cured of these diseases before he can possibly be cured of his 
speech malady. In other words, he must learn to control 
himself before he can hope to control his speech. 

Correct habits of respiration have to be learned, for 
as a rule the stutterer has not learned how to breathe 
properly. Although adenoids, enlarged tonsils, im- 
pacted teeth, etc., should always be carefully attended 
to, it should be understood that stuttering is n8t pri- 
marily an affection of the tongue, lips, palate, or 
pharynx. The stutterer's speech is faulty in every par- 
ticular. His whole nervous system is likely to be at 
fault. He may ''stutter" in his emotions, his thinking, 
and his willing. The trouble is more central than pe- 
ripheral. The treatment must have for its purpose a 
reeducation of the individual's speech habits, the gen- 
eral upbuilding of his physical health and the improve- 
ment of his mental condition. 

Stuttering is more an educational than a medical 
problem. The contention sometimes voiced, that the 
disease is one which can be successfully and legally 
treated only by a physician, is an absurd and education- 
ally pernicious doctrine. Not one physician in a thou- 
sand knows any more about the treatment of stutter- 
ing than he does about the teaching of Sanskrit. It is 
essential, however, that stutterers be kept under close 



354 THE HYGIENE OF THE SCHOOL CHILD 

medical supervision for the improvement of general 
health and for the treatment of specific physical de- 
fects. The actual task of working over the speech 
habits of the stutterer can be more successfully accom- 
plished by special teachers in the public schools at only 
a small fraction of the expense that would attach to the 
prolonged services of a competent physician. Speech 
defectives have been too long exposed to the question- 
able practices of institutions conducted for gain. 
Wherever stuttering is dealt with in the European way, 
it is cured easily, quickly, and at insignificant expense. 

It is plainly the duty of our normal schools to give 
the special training needed for this work. If at least 
one normal school in each State offered an annual 
course in orthophonia, we should soon have the requi- 
site number of special teachers. European experience 
shows that the training can be secured in a course 
extending over a single year with one or two lessons per 
week. The training should include not only theory, 
but also demonstration and practice. 

But the classroom teacher does not need to wait for 
the educational machinery to move. With a little time 
and much patience any sensible teacher can accom- 
plish a great deal in the improvement of defective 
speech. The work of Liebmann proves that the ex- 
tremely elaborate drills in articulation, enunciation, 
and breathing used by some specialists are by no 
means always essential to success. The following 
simple directions will be found helpful : — 

Arrange with the child to remain a half-hour after 



SPEECH DEFECTS 355 

school three or four times a week for a speech lesson. 
Let this consist largely of conversation in the low 
ordinary tone of voice. Convince the child that he will 
be able to overcome the defect. Repeat this assurance 
until it becomes an absolute conviction. Stuttering 
will ordinarily not cease as long as the fear of stuttering 
remains. Stuttering is really a speech phobia. Embar- 
rassment always aggravates it. The child stutters 
because he is convinced he will stutter. He sings nor- 
mally; hence the trouble does not lie in the speech 
organs themselves, but in their control. Control is 
balked by emotional stresses, or "repressed emotional 
complexes." The stutterer is tense. The followers of 
Freud claim that stuttering is always a form of anxiety 
neurosis. The patient must be freed from the morbid 
anxieties which have their seat in the subconscious life. 
Sometimes the whole character needs t6 be reformed. 
The patient, being oversensitive, may be suspicious of 
others, always on the lookout for signs of unfriendli- 
ness. He must be taught to take a reasonable attitude 
toward his defect and toward people. Disagreeable, 
experiences which have been repressed and embedded 
in the subconscious life should be dug up and recon- 
ciled with the daylight of consciousness. The stutterer 
is a victim of internal mental conflicts. He is nearly 
always subject to doubts, scruples, hesitation, etc. 
As Freud and Appelt have shown, these may be dissi- 
pated by the methods of psychoanalysis. It appears, 
however, that any kind of treatment will accomplish 
the same result which encourages self-confidence. 



356 THE HYGIENE OF THE SCHOOL CHILD 

fosters reasonableness, and loosens the inhibitions. 
The stutterer must learn how to relax. 

The fear of stuttering can only be relieved by a little 
experience with successful speech. The foundation for 
this can be laid in simple exercises in singing. The 
patient is thus convinced that untrammeled enuncia- 
tion is possible to him. Exercises in repeating easy 
sentences are also helpful. As self-confidence grows, 
these may be replaced by declamation. Always en- 
courage the child. Call his attention to the slightest 
sign of improvement. Dwell on successes; lead him to 
forget the failures. 

In the child's reading and conversation, cultivate 
expressiveness and melody. The stutterer, as has been 
shown by the researches of Scripture, jerks out his sen- 
tences almost in a monotone. Such a sentence as 
"How do you do?" is droned out in an uninflected 
tone which may be represented as follows : — 



Vow 



FIG. 23 

Line indicating the monotony of the stutterer's 
voice. (After Scripture.) 

The melody drill should be kept up until the child can 
say: — 




«w you 

FIG. 24 
Line indicating how the normal voice should 
rise and fall in speaking the phrase "How 
do you do ? " (After Scripture.) 



SPEECH DEFECTS 357 

Further details as to methods of curing stuttering, 
together with elaborate exercises and directions will be 
found in the excellent book by Scripture, which should 
be in the hands of every teacher who has a stuttering 
child in her class. 

The treatment proper should not be given in the 
presence of other children, though two or more stut- 
terers may be treated together. Encourage the child 
to recite frequently in his regular classwork, and never 
correct his defective speech in the presence of his class- 
mates, or even appear to notice it. The stuttering 
child is often among the brightest in the class. Take 
care to see that he lives up to his best level of per- 
formance. Do not permit him to fail even in unim- 
portant matters, where it can be avoided. Show 
interest and confidence in him as regards all sorts of 
things, in school and out. If partiality in a teacher were 
ever forgivable it would be in the case of the timid 
stutterer. It is also well to talk with the parents, both 
to explain your efforts in the child's behalf and to 
urge their cooperation. Without alarming them with 
exaggerated statements regarding the seriousness of 
the defect, explain clearly the handicaps which it 

involves. 

The prevention of stuttering 

The best time to cure stuttering is before it begins. 
It is important, therefore, that every teacher have 
some knowledge of speech disturbances and the hy- 
giene of the voice. She should understand that worry, 
embarrassment, and excitement are important imme- 



358 THE HYGIENE OF THE SCHOOL CHILD 

diate causes of speech defects. In the words of Conradi 
(3): '*If the school is a place of nervous tension; if the 
child is constantly worried with abstractions ill-fitted 
for the child mind; if it is asked to express its confused 
ideas under the eye of an ever critical teacher who 
conceives of her day's work as six long hours of weari- 
some labor — we have the ideal conditions for the 
onset of functional speech disturbances." 

Physical defectiveness and general health should be 
looked after with especial care in the case of weak, 
nervous children who show any tendency to speech 
defect. A life of quiet and calm should be fostered. 
Self-confidence should be diligently cultivated, for it 
is the nervous child's chief defense against stuttering. 
To upbraid the child for any imperfection of speech 
is not only brutal, but is certain to confirm and exag- 
gerate the defect. 

Any tendency to hurried, blustering speech should 
receive early attention. The success of the "melody 
cure" in the treatment of stuttering suggests the 
great importance of the cultivation of melody and 
expressiveness in the lower grades as a means of pre- 
venting the onset of the disease. 

At least one fourth of the children who enter the 
first grade of school have not fully recovered from the 
lisping and speech clumsiness of childhood. It is 
mostly from these pupils that the ranks of stutterers 
are recruited. For this reason, Rouma and others 
have urged that the first months of the school be given 
over to informal exercises in oral language designed 



SPEECH DEFECTS 359 

to get the children once for all into correct habits of 
speech. There is no pedagogical justification for the 
anxious haste of the primary school to teach children 
to read. Moreover, if the informal oral work here 
recommended were substituted for some of the more 
formal work of reading and writing in the early months 
of the first grade, the transition from the free, play life 
of the kindergarten to the primary school would be 
made more easy and natural. If one half of the time 
usually wasted on nonsensical phonic drills were 
devoted to the cultivation of an easy and pleasing 
.conversational voice not only would many cases of 
stuttering be prevented, but the traditional ^Ameri- 
can voice" would lose some of its disagreeable flavor.^ 
We should attach as much value to the correction of 
slovenly and disagreeable speech as to the correction 
of spelling, grammar, and manners. Speech habits are 
only plastic till adolescence, and the responsibility 
of teachers in the cultivation of speech is therefore 
very great. Melody and expressiveness of utterance 
should be an important aim of the school. If every 
child were given the treatment appropriate to the 
incipient stutterer, no one would suffer thereby and 
the speech of even the normal children would be 
greatly improved. 

^ As characterized by Scripture, the "American voice" has three 
chief qualities: (1) hardness, due to excessive innervation; (2) the 
drawl, or slurring, due to speech laziness; and (3) nasal resonance, 
due partly to habit and partly to catarrhal conditions. 



360 THE HYGIENE OF THE SCHOOL CHILD 

Suggestions for observing speech defects 
Does the child stutter? 

Does he lisp (substitute certain sounds for others) ? 
Is the child " tongue-tied " ? 
Has baby-talk persisted unduly? 
Is speech rapid or blustering? . 
Is speech jerky (staccato)? 
Is speech slow or drawling? 
Is the child unable to respond promptly? 
Is enunciation careless (sounds slurred over or dropped)? 
Is speech indistinct (words "chewed")? 
Is the voice high-keyed or shrill? (Indication of nervous- 
ness.) 

Does the child speak in monotones? 

Has the speech exaggerated inflection? 

Is it too loud? 

Is it too low to be easily heard over the room? 

Has the voice a nasal quality? (Adenoids, etc.) 

Is there chronic hoarseness? 

Has the voice changed? (Indication of puberty.) 

Is there abnormal hoarseness? 

Is dentition normal? 

REFERENCES 

*1. Alfred Appelt: Stammering and its Permanent Cure; A Treatise 

on Psycho- Analytical Lines. London, 1911, pp. 234. 
*2. P. B. Ballard: "Sinistrality and Speech." Jour. Exp. Ped. 

(London), 1912, pp. 298-310. 
*3. Edward Conradi: "The Psychology and Pathology of Speech 

Development." Ped. Sem., 1904, pp. 327-80. 
4. Edward Conradi: "Speech Defects and Intellectual Progress." 

Jour. Ed. Psych., 1912, pp. 35-38. 
6. Anton Elders: Heilung des Stotterns nach gesanglichen Grund- 

satzen. Leipzig, 1912, pp. 68. 

6. P. H. Gerber: Die Menschliche Stimme u. ihre Hygiene. Leip- 
zig, 1907, pp. 137. 

7. Godfring: "Die Psychische Beeinflussung stotternde Kinder." 
Zt. f. Schulges., 1906, pp. 317-23. 

*8. Leonard Guthrie: The Functional Nervous Disorders of Child- 
hood. 1909, pp. 262-94. 



SPEECH DEFECTS 361 

9. A. Gutzmann: Uebungbuchf. d. Hand des Schulers. 1911, 14th 

edition. 
*10. A. Gutzmann: Das Stottern. Berlin, 1910, 6th edition. 
*11. H. Gutzmann: Sprachheilkunde. Berhn, 1912, 2d edition, pp. 

646. 
*12. Dr. Hudson-Makuen: "A Brief History of the Treatment of 

Stammering, with some Suggestions as to Modern Methods." 

Pennsylvania Med. Jour., December, 1909. 

13. Dr. Hudson-Makuen : " The Treatment of Stammering." Jour. 
; Amer. Med. Assoc, September, 1910. 

14. Adolf Kussmaul: Die Siorungen der Sprache. Leipzig, 1910, 4th 
edition, pp. 409. 

15. G. A. Lewis: "Cure of Stammering and Stuttering." Amer. 
Phys. Ed. Rev., 1903, pp. 249-59. 

16. G. A. Lewis: Practical Treatment of Stammering and Stuttering, 
and a Treatise on the Cultivation of the Voice. Detroit, 1902, 
pp. 415. 

*17. Michael Levine: "Preliminary Report on the Treatment of 
Stuttering, Stammering and Lisping in a New York School," 
Psych. Cliyiic, 1912, pp. 93-106. 

*18. Albert Liebraann: Vorlesungen iiber Sprachstorungen. Berlin, 
1898 to 1909. ^ 

19. Cortland MacMahon: "Curative Treatment of Stammerers." 
School Hygiene, 1911, pp. 315-21. 

20. T. J. McHattie: "The Educational Treatment of Stammering 
Children." School Hygiene, 1911, pp. 308-14. 

21. E. Paulsen: "Ueber die Singstimme der Kinder." Pfliige/s 
Archives, 1895, pp. 407-76. 

*22. George Rouma: "Enquete scolaire sur les troubles de la parole 
chez les ecohers beiges." Inter. Mag. Sch. Hyg., 1906, vol. ii, 
pp. 151-90. 

*23. George Rouma: " L'Organization de cours de traitement pour 
enfants troubles de la parole," Inter. Mag. Sch. Hyg., 1907, 
vol. Ill, pp. 116-71, 

*24. E. W. Scripture: Stuttering and Lisping. 1912, pp. 251. (The 
most important work on the subject in English. Gives direc- 
tions for treatment.) 

, 25. Eric B. Smith: "An Investigation of Some Causes of Defective 
Speech in Elementary Schools," School Hygiene, 1912, pp. 
143-54, 

26, Clara Harrison Town: "Language Development in 285 Idiots 
and Imbeciles." Psych. Clinic, 1913, pp. 229-35. 

27, Harry P. Weld: "The Mechanism of the Voice and its Hy- 
giene." Ped. Sem., 1910, pp. 143-59. (Pertains mostly to sing- 
ing.) 



CHAPTER XX 

THE SLEEP OF SCHOOL CHILDREN i 

Sleep and food are two of the most imperative 
needs of the human organism. Each has its educational 
and economical, as well as its physiological and 
biological, aspects. But while diet has long received 
a liberal share of attention from economist, hygienist, 
and biologist, the scientific study of sleep has been 
hardly more than initiated. 

Sleep is one of the biological rhythms stamped into 
the organism by the movements of the planet on 
which we live. To interfere unduly with such an an- 
cient and physiologically established rhythm would 
theoretically appear to be an unsafe experiment. It is 
an instinct which involves the entire body, and is not 
simply a function of the brain. The brainless dogs of 
Golz and the brainless pigeons of Manaceine exhibited 
the same sleep rhythms after the removal of the cere- 
brum as before. Psychiatrists tell us that many 
mental disorders are preceded by protracted insomnia. 
Loss of sleep has been experimentally shown to cause 
a decrease in the number of red corpuscles, while the 
beat of the heart is accelerated to compensate for the 
poverty of the blood. Far from being a bad habit, as 

1 Written with the assistance of Adeline Hocking, Stanford 
University. 



THE SLEEP OF SCHOOL CHILDREN 363 

Girondeau believed, sleep has been evolved as the best 
biological means of making possible intense periodic 
activity of mind and body. 

Besides acting to recharge the batteries of life, sleep 
has a settling and confirmatory influence upon the 
mental activities which precede it. To "sleep over a 
problem" is a means of transforming a chaos of 
puzzled mentation into order and clarity. The learn- 
ing processes which are initiated during the work of 
the day take deeper root during the hours of sleep. 
In sleep, life purposes may mature and ideals take 
shape. 

On the other hand, we must avoid overestimating 
the hours of sleep necessary. Sleep is but one of the 
many needs of children, and it is foolish to make it the 
scapegoat for all kinds of physical and mental evils, as 
hygienists have so often done. It is possible that the 
quantity of sleep is less important than its quality, 
and when disturbances of the latter occur, they are 
likely to be the effect of the ill health rather than its 
cause. 

The amount of sleep needed 

On this point we have a large number of estimates 
based upon opinion, but no certain knowledge. The 
theoretical norms set forth by Dr. Duke have been 
very generally accepted. Other noteworthy stand- 
ards are those of Hertel, Bernhard, and Claparede. 
The difference of opinion which prevails is shown in 
Table 31. 



364 THE HYGIENE OF THE SCHOOL CHILD 
TABLE 31. ESTIMATE OF SLEEP NEEDS (HOURS) 



Age 


5 

to 7 
6 


8 

12^ 


9 
12 


10 

lU 


11 


12 


13 
10 


14 
10 


15 

94 


16 


17 


18 


Duke 


ISh 


13 


11 10| 


9 


9 


8i 


Bernhard. . 




U 


11 


11 


10^ 


10^ 


10 


10 


94 










Hertel .... 


11 


10^ 


10^ 


10 


10 


9^ 


9* 


9* 


9 


9 


8f 






Claparede. . 


lU 


lU 


lU 


lOi 


10^ 


n 


94 


H 


9 


9 








Manaceine . 


14 


11 


11 


11 


10 


10 


H 


Si 


84 


8 


8 to 7 






Krollich.... 


11 


11 


11 


11 


loi 


lOi 


10 


10 


94 


9 


9 


84 


8i 


Cavanagh . 




12 






















9 


Brown .... 


IH 












10 














Pfaunder . . 


11 












9 














Key 


11 












10 















The above table shows a difference of opinion 
amounting to 2 J hours for the age 6, 2 J hours for age 
7, 2 hours for age 8, 2 hours for age 9, etc. Duke recom- 
mends as many hours for age 18 as Manaceine for age 
13; and as many hours for age 14 as Manaceine for 
age 10. Duke's estimate for 11 years equals Key's for 
6 years. In like manner, twenty-nine medical officers 
of English schools, who were interrogated by Acland 
(1), estimated the sleep needs of 12-year-old boys all 
the way from 9 hours to more than 10. 

Several investigations have been made of the num- 
ber of hours children do sleep, though obviously we 
cannot in this way determine conclusively how many 
hours they ought to sleep. One of the earliest of these 
was by Hertel, who in his study entitled "Overpres- 
sure in the Schools of Denmark" presents sleep records 
from 3141 boys and 1211 girls in the schools of Copen- 
hagen. These averaged about 10 J to 11 hours of sleep 
at 6 years, the amount decreasing to 9 J hours at 12 
years, and to about 8 J at 16 years. Sleep was most 
deficient among pupils pursuing the arduous classical 



THE SLEEP OF SCHOOL CHILDREN 365 

courses, where it often fell to 6 or 7 hours. Acland 
found that the hours of "undisturbed rest" given to 
boys 10 to 13 years of age in forty English boarding- 
schools ranged from 8 to 10, averaging about 9. The 
actual time of sleep must have been somewhat less 
than this, and was certainly far below the amount 
physicians usually consider desirable. 

Important investigations of the sleep of school chil- 
dren are those of Dr. L. Bernhard (S) and Dr. Alice 
Ravenhill (14). The former secured data from 6551 
German children 6 to 14 years of age, and the latter 
from 6180 English children of about the same ages. 
The average amount of sleep for each year is sHbwn in 
the following table : — 



TABLE 32. SLEEP OF GERMAN AND ENGLISH 
CHILDREN 



Age 


Sleep in hours and minutes 


6 


7 


8 


9 


10 


11 


12 


13 


Bernhard 
Ravenhill 


10.20 
10.30 
10.45 


9.50 
10.30 
10.30 


9.25 

9.30 

10.15 


9.20 
9.15 
9.30 


9.10 
9.15 
9.30 


8.55 
8.45 
9.15 


8.25 
8.15 
8.00 


7.50 

8.30 Boys 
7.30 Girls 



Using his own estimate of the amount of sleep which 
children ought to have, Bernhard computes that the 
sleep deficiency among his 6551 pupils ranges from 
about an hour at the age of 7 to nearly an hour and 
three quarters at 14 years. This would represent a 
total sleep loss per year of over 400 hours for the aver- 
age child of 6, and over 600 hours for the average child 



366 THE HYGIENE OF THE SCHOOL CHILD 

of 14 years. Miss Ravenhill, basing her estimate upon 
the standards furnished by Dr. Duke, finds an average 
sleep deficiency for Enghsh children of nearly 25 per 
cent; while that for girls of 13 years amounts to a 
daily loss of 3 J hours. Children of 6 years were found 
who slept only 7 hours, and children of 12 years, 4 to 
6 hours. 

During the year 1911-12 the writer, with the assist- 
ance of Miss Adeline Hocking, carried out an investi- 
gation of the sleep of school children, which had for 
its purpose, (1) to ascertain by more careful methods 
than had yet been employed the hours of sleep of 
children in the Western States of America; (2) to 
discover what correlation exists between hours of 
sleep and school success; and (3) to find the relation of 
hours of sleep to social status, home study, and the 
possession of typical "nervous" traits. Records were 
secured from 2692 children between 6 and 20 years 
of age in the California cities of Stockton, San Jose, 
Alameda, and Los Gatos; Tempe, Arizona; and Mon- 
mouth, Oregon. 

By means of a carefully planned and uniform pro- 
cedure data were secured showing the exact time of 
retiring, the approximate length of time required for 
going to sleep, the exact time of waking, whether 
waking was spontaneous, how many other persons 
slept in the same room and the same bed, and the 
amount of ventilation in the bedroom. 

The amount of sleep for these 2692 persons is shown 
in hours and minutes in the following table: — 



THE SLEEP OF SCHOOL CHH^DREN 367 



TABLE 33 



Age 


No. of 
records 


Av. no. of 
hrs. of sleep 


Age 


No. of 
records 


Av. no. of 
hrs. of sleep 


6- 7 


37 


11.14 


13-14 


250 


9.31 


7- 8 


147 


10.41 


14-15 


244 


9.06 


8- 9 


218 


10.42 


15-16 


201 


8.54 


9-10 


291 


10.13 


16-17 


167 


8.30 


10-11 


307 


9.56 


17-18 


117 


8.46 


11-12 


282 


10.00 


18-19 


43 


8.46 


12-13 


312 


9.36 


University 












students 


51 


7.47 



The most important fact in the above table is the 
striking excess of sleep among these children as com- 
pared with the German and English children of Bern- 
hard and Ravenhill. This excess amounts fo^ most 
ages to between one hour and one hour and a half. 
At the same time the sleep averages found in this 
investigation fall from three fourths of an hour to two 
hours below the theoretical standards set by Dr. Duke. 

jirs, 6 7 8 9 10 11 12 13 




FIG. 25 
Amount of sleep children actually receive compared to Duke's theoretical 

standard 



368 THE HYGIENE OF THE SCHOOL CHILD 



Age 6 

Hours 

13 



These points of difference are shown graphically in 
figure 25. 

An idea of the individual differences may be gained 
from figure 26, which shows an average difference of 
three to four between the ten highest and ten lowest 
for each age. 

It is seen, therefore, that the average amount of 
sleep received by children in the western part of the 
9 10 11 12 13 14 15 16 United States very 

greatly exceeds 
that for German 
and English chil- 
dren. This may be 
accounted for by 
the differences in 
climate and in the 
amount of out- 
door living (which 
is known to favor sleep), by the better home envu*on- 
ment of our pupils, and by the relatively late hour of 
beginning the school day in this country. 

Our average would have been still higher had all 
the children been permitted to sleep until they awak- 
ened spontaneously. The following table shows the 
percentage in each year who had to be awakened : — 




FIG. 26 
Showing extremes in amount of sleep secured at 
different ages. (Terman and Hocking.) 



TABLE 34 

Age 6 7 8 9 10 11 13 13 14 15 16 17 18 

Per cent 
awakened 21.2 19 23.3 19.1 22.8 20.3 23.6 24.7 26 31.6 88.7 39.9 47.7 



The interesting fact here is the rapid increase in early 



THE SLEEP OF SCHOOL CHILDREN 369 

adolescence of the number who did not wake spon- 
taneously, probably due to the fact that a majority of 
the records above the age of 14 were from high-school 
pupils, who were required to do more evening work 
than the younger children. 

Although it cannot be assumed that averages secured 
in this investigation furnish absolutely reliable norms 
of the amount children of various ages ought to sleep, 
it is believed that they are of more value for compara- 
tive purposes than any which have hitherto been avail- 
able. The averages of Bernhard and Ravenhill prob- 
ably show a sub-normal amount of sleep, while the 
traditionally accepted norms of Duke are c^tainly 
too high. 

The relation of sleep to intelligence, to social statusy 
and to nervous traits 

In order to throw light on these points, supplemen- 
tary information was secured from each of 1350 out of 
the total 2692 individuals. This included the degree 
of intelligence as estimated by the teacher on a scale 
of seven, the social status of the home as estimated on a 
scale of four, the number of "nervous " traits possessed 
by the child, and his school success. School success was 
measured by the child's grades in the different sub- 
jects received at the end of the previous quarter or 
semester. Correlations were then computed, for the 
different ages separately, by the well-known Pearson 
formula. 

In every case it was found that there was practically 



370 THE HYGIENE OF THE SCHOOL CHILD 

no correlation, either positive or negative, between 
sleep, on the one hand, and intelligence, social status, 
"nervous" traits, or any school subject, on the other. 
The instances in which the coefficient of correlation 
exceeded +.10 or — .10 were so few and appeared so 
sporadically in the different ages as to be wholly with- 
out significance. It was even found that the school 
grades of the pupils sleeping the least averaged slightly 
above those of the ten sleeping the most. 

How are we to explain a result so at variance with 
current belief.? 

One interpretation would be that the average child 
receives more sleep than he really needs. It has been 
experimentally shown that sleep ordinarily becomes 
superficial after four or five hours, and it has been 
suggested that this period of less effective sleep might 
be considerably shortened without material loss. In 
harmony with this, Weygandt's tests of mental effi- 
ciency seemed to indicate, for himself, complete recov- 
ery from the most difficult kinds of mental work after 
five hours of sleep (19). On the other hand, Netscha- 
jeff's experiments on the relation between his own 
sleep and mental efficiency during a period of four 
months show that the latter was affected by extremely 
slight deficiencies of sleep. Further investigation is 
urgently needed. 

A second explanation of the lack of correlations is 
offered by the theory that quantitative differences in 
sleep may be offset by qualitative differences. If such 
qualitative differences exist, then sleep cannot be 



THE SLEEP OF SCHOOL CHILDREN 371 

accurately measured in units of time alone. The 
observations of Gilbert and Patrick (13), who for 
experimental purposes went without sleep for ninety 
hours, showed that only a small fraction of the sleep 
lost (one third to one sixth) was later made up, but 
that the sleep which followed the experiment was much 
more profound than usual. 

A third explanation relates to "the factor of safety." 
This may be sufficiently large to enable both body and 
mind for many years to withstand with apparent suc- 
cess a real and considerable sleep deficiency, while at 
the same time the reservoir of energy is being insidi- 
ously depleted. It would be rash to infer that a mode of 
life is safe merely because it does not produce immedi- 
ate and evident injury. The factor of safety must be 
kept intact. We want not merely the strength to do 
the average work of each day, but we need to keep 
the reservoirs of energy well supplied, so that we may 
withstand the sieges of deprivation, disease, accident, 
and overwork which are almost inevitable. 

In the fourth place, the lack of correlation between 

sleep and intelligence may be accounted for on the 

hypothesis that the heightened brain activity which is 

necessary for high-grade intellectual processes involves 

a kind of neural excitement which itself predisposes 

to wakefulness. To test this hypothesis, sleep records 

were secured from 383 feeble-minded individuals, 

from 6 to more than 60 years of age, in the Vineland 

Training School.^ Figure 27 shows the results for the 

1 The writer is indebted to Superintendent E. R. Johnstone and to 
Dr. H. H. Goddard for supplying the records for this comparison. 




S72 THE HYGIENE OF THE SCHOOL CHILD 

193 feeble-minded children whose ages fell between 6 
and 19 years. For sake of comparison the curve for 
Hours o^^ normal children 

is reproduced. 

It is seen that the 
feeble-minded chil- 
dren sleep much 
less than normal 
children of the 
Agee 7 8 9 10 1112 1314 15 1617 1819 same age, the fee- 
FiG. 27 ble-minded adults 

Sleepof mentally defective children compared with mUch mOrC than 
that of normals. (Terman and Hocking.) 

normal adults. As 
regards sleep, the feeble-minded retain throughout life 
the characteristics of childhood. Otherwise there seems 
to be little relation between the amount of sleep and 
the grade of intelligence. 

As regards the school child, in all probability, the 
wisest course is for us to make the conditions such that 
the child will sleep as many hours per day as he wants 
to sleep. We should avoid either abbreviating or 
unduly prolonging the sleep beyond this standard. 
Liberal allowance should also be made for individual 
differences. There are probably physiological idiosyn- 
crasies which make nine hours for one child equivalent 
to eleven hours for another. 

The conditions of children's sleep 

The conditions of sleep may be roughly classified 
under two headings : (a) the external or environmental. 



THE SLEEP OF SCHOOL CHILDREN 373 

and (6) the internal or individuaL Under the former 
may be considered such matters as the following : — 

(1) Housing conditions. There is probably no sec- 
tion of the country where crowding is less common 
than in the Western States; but of the 2692 children 
who entered into this investigation, only 32 per cent 
have a bedroom to themselves, while 16.4 per cent 
share the sleeping-room with two other persons, and 9 
per cent with three or more. 

(2) Ventilation. The following table reveals the bed- 
room ventilation of our 2692 pupils for the different 
ages. The first column shows that the number sleep- 
ing practically without ventilation is much sn^Uer in 
the later years. This is no doubt partly the result of 
hygiene instruction in the vschool. 



TABLE 35 







Ventilation 


of bedrooms 






Age 














No window 
open 


One open 


More than one 
open 


Open-air 




6 


40.6% 


43.8% 


12.5% 


3.1% 




7 


38. 


52.5 


8. 


1.5 




8 


28.5 


58.1 


9.3 


4.1 




9 


28.4 


56.2 


12.1 


3.3 




10 


24.6 


57.8 


14.5 


3.1 




11 


26. 


56.4 


14.5 


3.1 




12 


19.6 


63.5 


13.6 


3.3 




13 


16.6 


62. 


16.6 


4.8 




14 


10.2 


66.6 


20.8 


2.4 




15 


14. 


69. 


14.6 


2.4 




16 


5.2 


67.8 


25. 


2. 




17 


6.5 


70.4 


18.5 


4.6 




18 


2.5 


78. 


17. 


2.5 





Any teacher who will go to the slight trouble nee 



374 THE HYGIENE OF THE SCHOOL CHILD 

essary to make a sleep survey in her school will 
find enough, not only to astonish her, but to give her 
some valuable suggestions for the teaching of practical 
hygiene. In this case it was found that 47 per cent of 
those sleeping with no windows open were sharing the 
bedroom with at least two other persons ! 

(3) Work. Five per cent of Ravenhill's boys rose 
regularly before 5 a.m. for various kinds of work. Of 
the 6-year-old boys, 2 per cent were engaged in gainful 
occupations out of school hours. This rose to 28 per 
cent at 11 years and to 53 per cent at 12.^ Almost any 
teacher in city schools above the sixth grade will find, 
if she takes the trouble to inquire, a certain number of 
pupils in her class who are engaged in remunerative 
labor from 10 to 20 hours per week. 

(4) Hours of retiring. Nearly 5 per cent of Raven- 
hill's 6-year-old children retire as late as 10 o'clock, and 
nearly 10 per cent of her 10-year-olds. The time lost 
in this way cannot be fully made up in the morning 
because of the disturbance caused by the early rising 
of parents, and because of the necessity of getting to 
school at a given hour. In other words, the hours set 
apart for the sleep of children are not always those best 
adapted to insure a sufficient amount. Even the fam- 
ilies who set a reasonably early hour for the children 
to retire usually permit so many irregularities that, as 
one writer puts it, "the law is more observed in the 
breach than in the performance." Ravenhill found 

1 In our own study the returns on this point were unreliable 
because of an unfortunate wording of one of the questions. 



THE SLEEP OF SCHOOL CHILDREN 375 

that 20 per cent at 6 years, and 40 per cent at 13 years, 
were allowed one or more irregularities per week. The 
European custom of beginning school at 7 to 8 o'clock 
in the morning works great hardship, often causing the 
pupil to rush away to school in nervous haste and with- 
out breakfast. Nine o'clock is far better. 

(5) Vermin. Medical examiners sometimes find from 
10 to 40 per cent of the pupils of a school affected 
with vermin. Needless to say, the child who is so 
tormented cannot secure normal sleep. Other parasitic 
diseases, such as scabies (*'itch"), ringworm, and 
intestinal worms, should be mentioned in this connec- 
tion. ' ^ 

(6) Miscellaneous conditions. The sleep of school 
children is influenced in many other ways. Tempera- 
tures much above 60 degrees are unfavorable both to 
quantity and quality of sleep; hence children sleep 
more in the winter than in summer. The late sunrise 
of winter mornings exerts an influence in the same 
direction. Humidity and atmospheric pressure are 
other factors, though their exact effects have not yet 
been determined. Some children sleep poorly for lack 
of a bed or because of insufficient protection from cold. 
Still others are aroused by the din of early street 
noises. 

Internal conditions influencing sleep 

Improper diet is one of the most important of these. 
The child's sleep may be disturbed by excess of 
starchy foods, unsuitable cooking, etc. The late 



376 THE HYGIENE OF THE SCHOOL CHILD 

dinner, following an inadequate breakfast and cold 
unsatisfying noonday meal, favors engorgement of the 
stomacli, and is therefore unfavorable to sleep. 

The influence of tea and coffee upon sleep is a matter 
of common observation. The experiments of Hollings- 
worth (8) on ten men and six women, extending over 
a period of forty days, verify common opinion on this 
point, and show further that the influence of caffeine 
is in inverse proportion to the weight of the subject. 
One cup of coffee for the 7-year-old child is therefore 
equivalent to three cups for the average adult. Even 
this may understate the facts, since it is probable that 
the child's body does not adjust and become habitu- 
ated to the evil effects of drugs as well as the body of 
the adult. Dr. E. B. Hoag finds, from questioning 
many thousands of school children, that about 80 per 
cent drink coffee or tea daily, and that many young 
children drink from three to six cups daily. Hundreds 
of thousands of school children in the United States 
are kept in a constant state of semi-intoxication by the 
use of coffee and tea. 

The nervous child is notoriously a bad sleeper. Such 
a child is likely to be obsessed by fears, tormented by 
absurd pangs of conscience, excited by an over-active 
intelligence, or worried by trivial happenings which 
would be forgotten by the normal child in a few min- 
utes. Religion-bred fears, fear of the dark, and vague 
indefinable anxieties haunt the evening hours of more 
children than most of us suspect; for children learn 
that it is pleasanter to bear many a secret pain and 



THE SLEEP OF SCHOOL CHILDREN 377 

sorrow than to hazard reproof and misunderstanding 
by imparting them to unsympathetic elders. 

Home study robs many a nervous child of the needed 
margin of sleep. It not only causes him to remain up 
later, but is likely to induce an excited condition of 
mind which is followed by superficial and disturbed 
sleep. Arithmetic lessons are especially unsuited for 
home assignments, but because of their quality of 
definiteness they are just the kind of homework with 
which children are most likely to be burdened. 

Other common causes of disturbed sleep are ob- 
structed breathing, eye-strain, dentition, earache, 
toothache, etc. ^ 

In children over eight years of age night terrors are a 
common disturbance. They are occasionally provoked 
by indigestion, obstructed breathing, or other reflex 
irritations, but in most cases of chronic recurrence they 
are associated with other hereditary nervous taints, 
notably migraine. The condition is then indicative of 
general nervous instability. The child who suffers from 
night terrors deserves special oversight on the part of 
parent, teacher, and physician. Often it is wise to 
remove such a child from school. 

Teaching children to sleep 

That only 3.1 per cent of the school children in the 
mild and equable climate of California enjoy open-air 
sleeping-rooms suggests what remains to be done in 
this line of instruction. 

The teacher should know the poor sleepers in her 



378 THE HYGIENE OF THE SCHOOL CHILD 

classes and those who suffer night terrors or other 
fears and obsessions which interfere with sleep. She 
should know which children drink coffee, tea, and beer; 
which ones sleep in crowded and ill-ventilated bed- 
rooms. By means of a series of questions the teacher 
ought every year to make a sleep survey of her pupils. 

• Suggestions for a sleep survey of school children 

1. What time do you usually go to bed? 

2. How many times per week do you go to bed later than 
this? How much later? 

3. How long does it usually take you to go to sleep? 

4. At what hour do you usually wake? 

5. How many times a week do you sleep later than this? 
How much later? 

6. Does some one wake you (call you) in the morning? 

7. Do you ever have dreams that frighten you? How often? 
What are they usually about? 

8. Are you afraid to sleep in a room alone? 

9. How many other persons sleep in the same room with 
you? 

10. How many other persons sleep in the same bed with you? 

11. How many windows are there in your bedroom? 

12. How many windows did you have open last night? 

13. How wide were they open? 

14. Do you sleep in an ordinary room, or out of doors, or on 
a sleeping-porch? 

15. Do you study your lessons at home? What lessons? 
What time in the day or night do you do home study? 
How many minutes or hours of home study each day? 

16. Do you take private lessons (that is, out of school) in 
music, painting, etc.? If so, how much time does this take 
each day? 

17. Have you regular work to do outside of school, such as 



THE SLEEP OF SCHOOL CHILDREN 379 

selling papers, doing chores, helping parents, or any- 
thing else of this kind? If so, how much time does it take 
each day? 

To avoid the possible effect of suggestion, it is neces- 
sary to give the questions without previous discussion 
of any kind. All remarks regarding the desirability of 
bedroom ventilation, sufficient sleep, etc., should be 
postponed until after the answers have been secured. 
If this precaution is not observed, the children are 
likely to shape their answers to please the teacher, 
instead of giving facts. It is best to distribute mimeo- 
graphed copies of the questions for the children to 
answer in writing. % 

REFERENCES 

(For additional references on sleep the reader is referred to the 

extensive bibliographies of Manaceine and Sidis.) 

*1. T. D. Acland: On Hours of Sleep in Public Schools. J. and A. 

Churchill, London, 1905, pp. 35. 

2. J. Mace Andress: "An Investigation of the Sleep of Normal 

School Students." Journal of Educational Psychology, March, 

1911, pp. 153-56. 

*3. Dr. L. Bernhard: "Schlafzeit der Kinder." Encyclopadie der 
Modern Kriminalistik, vol. ii. 

*4. E. Claparede: Experimental Pedagogy and the Psychology of the 
Child. Longmans, Green & Co., New York, 1911, pp. 306-17. 

*5. E. Claparede: "Theorie biologique du sommeil." Arch, de 
Psychologic, vol. iv, 1905, pp. 245-349. 
6. Clement Duke: Remedies for the Needless Injury to Children. 
London, 1899, pp. 37. 

*7. Leonard G. Guthrie: Functional Nervous Disorders in Child- 
hood. Henry Froude, Hodder & Stoughton, London, 1909, 
2ded. 

8. H. L. Hollingsworth: "Influence of Caffein Alkaloid on the 
Quantity and Quality of Sleep." Am. Jour. Psych., January, 

1912, pp. 89-100. 

9. E. Jones: "On the Nightmare." American Journal of Insanity, 
January, 1910. 

*10. Marie de Manaceine: Sleep; Its Physiology, Pathology, Hygiene, 
and Psychology. London, 1897, pp. 341. 



380 THE HYGIENE OF THE SCHOOL CHILD 

11. Michelson: "Der Schlaf im Kindesalter." Psych. Arheiten, 
1899, vol. II. 

*12. Caroline Osborne: "The Sleep of Infancy as related to Physical 
and Mental Growth." Pedagogical Seminary^ March, 1912, 
pp. 1-47. 

*13. Patrick and Gilbert: "On the EfiPect of Loss of Sleep." Psycho- 
logical Review, vol. iii, pp. 469-83. 

*14. Alice Ravenhill: "Some Results of an Investigation among 
Children in the Elementary Schools of England." Internafl 
Mag. Sch. Hyg. vol. v, 1908, pp. 9-28. 

15. Alice Ravenhill: "Hours of Sleep among Elementary School 
Children." School Hygiene, July, 1910, 

16. Dr. Clive Riviere: "On Sleep." School Hygiene, 1912, pp. 109- 
18. 

17. Dr. Romer: "TJeber einige Beziehungen zwischen Schlaf u. 
geistigenTatigkeiten." Third Internal. Congress for Psychology, 
1896, pp. 353/. 

18. Boris Sidis: " Experimental Study of Sleep." Journal of Abnor- 
mal Psychology, vol. iii, pp. 1-32; 63-96; 170-99. 

*19. Weygandt: "Exper. Beitrage zur Psychologic des Schlaf es." 

Zeitschriftf. Psychologic, 1905, pp. 1-41. 
20. N. Vaschide: Le Sommeil et les Reves. 1911, pp. 305. (Has 

chapter on age and sex differences.) 
*21. Terman and Hocking: "The Sleep of School Children." Jour. 

Ed. Psych., March, April, and May, 1913. 



CHAPTER XXI 

SOME EVIL EFFECTS OF SCHOOL LIFE \ 

The school is a formal agency devised for the pur- 
pose of bringing the child into possession of the main 
body of our social inheritance, — the treasures of 
knowledge, culture, and skill laboriously accumulated 
by countless generations of ancestors. When these 
treasures were few and pertained mostly to the affairs 
of immediate self-preservation, there was little danger 
of overburdening the young in the process of their 
acquisition. To-day the case is different. The intri- 
cacy of present-day civilization has raised mountains 
of difficulties which must be met and overcome by all 
children who are not to become playthings of complex 
social and industrial forces. The period of infancy has 
not lengthened in proportion to the increased educa- 
tional demands upon it. The school term has been 
considerably lengthened, and for the first time in the 
world's history attendance has been made generally 
obligatory. 

That this situation involves certain physical dan- 
gers to the child is self-evident. Indeed, the charge of 
school overpressure has been made repeatedly for at 
least half a century. The complaints have come chiefly 
from physicians, professors of pedagogy, educational 
theorists, and parents; only occasionally from the school 



sa^ THE HYGIENE OF THE SCHOOL CHILD 

itself. Because of the wide variations in the severity 
of the school's demands upon its pupils, and because of 
the individual differences in the ability of children to 
meet these demands, it would be misleading to give a 
categorical answer to the question of overpressure. 

Every one will admit, however, that injury is some- 
times inflicted upon the child by the activities and 
^environment of the school. Almost every chapter 
In the present volume has presented evidence of such 
injuries. At the same time, the school is usually only 
one of several factors involved, and it is often impossi- 
ble to determine with certainty the exact share of each 
in the production of the ill health which has been 
found so prevalent among school children everywhere. 
That the school is one of the important causes is evi- 
denced by the results of many investigations. 

The school as a cause of morbidity 

Hertel's pioneer study (10) of the health conditions 
and work habits of 3141 boys and 1211 girls in the 
secondary schools of Denmark revealed what was then 
regarded an incredible amount of morbidity, and 
demonstrated suflficient correlations of morbidity with 
years of school attendance and with daily hours of 
study forcibly to suggest a cause-and-eflect relation. 
In the first two classes (children 8 to 10 years), the 
percentage of morbidity was only 18.4; that is, 18.4 
per cent were suffering from one or more chronic 
defects serious enough to impair health. By the end 
of the third year the amount rose to 34 per cent, and 



SOME EVIL EFFECTS OF SCHOOL LIFE 383 



by the end of the eighth year, with its average of 8^ 
hours of daily study, to nearly 50 per cent. The pupils 
whose studies were chiefly of a scientific nature showed 
a decidedly lower percentage of morbidity than that 
found among the students of classical courses. This 
was thought to be due to the heavier demands of the 
classical courses upon intellectual application and to 
the smaller opportunity afforded for physical activity. 
Conditions were even worse among the girls, among 
whom morbidity rose from about 30 per cent in the 
first two grades to over 60 per cent by the age of 12 to 
16 years. The sus- 
picion is justified 
that the daily pe- 
riod of study, which 
increased concomi- 
tantly from about 
seven to about nine 
hours, may have 
been causally re- 
lated to the increase 
in morbidity. 

The later study, 
made by Schmid- 
Monnard (19), of 
5100 boys and 3200 
girls in the second- 
ary schools of Ger- 
many, confirmed essentially all the findings of Hertel. 
The above figure from Schmid-Monnard shows 




12 13 



FIG. 28 
Showing increase of morbidity with age among 
1900 girls in German middle schools. (After 
Schmid-Monnard . ) 



384 THE HYGIENE OF THE SCHOOL CHILD 



the rise in morbid- 
ity among 1900 girls 
in a middle school 
and the correspond- 
ing increase of fre- 
quency for head- 
aches, insomnia, 
and outside employ- 
ments. 

Figure 29 shows 
similar correlations 
for 500 pupils in a 
girls' higher school. 
Roughly speak- 
ing, schools with 
both morning and 
afternoon sessions 
showed in the high- 
er grades nearly 
twice as much mor- 
bidity as schools 
with forenoon sessions only. This is shown in the fol- 
lowing table : — 



% 

85 
80 
75 
70 
65 
60 
55 
50 
45 
40 
85 
30 
25 
20 

15 
10 
5 














A 




















/ 


\ 




/ 












1 




S 


\/ 


/ 












/ 




















/ 


















^1 




















7 








/ 


"^ 










r/ 






A 


/ 










: 


f 






0/ 














\ 






7 


,r~- 


^^ 


< 






Qi 






• 


if 


/ 












A 


V 




i 












// 


/ 


^--^ 


il 












// 






i 


f 


















«t/ 












1 






^^^ 


sy 












1 


0^ 


f 


y' 




^lAl 


\^ 


y^ 


y 


y 


<h 


^ 




-- 


it^sPiii::: 









t 8 9 10 11 12 IS M: t5 16 

FIG. 29 
Showing increase of morbidity with age among 500 
girls in a German secondary school. (After 
Schmid-Monnard. ) 





TABLE 36 








Morning session only 


Morning and afternoon 
sessions 




Average 


Maximum 


Average 


Maximum 


Total morbidity 
Nervousness and 

Headaches 
Insomnia 


25% 

13. 
1.5 


39% 

28 
5 


50% 

25 
4 


74% 

62 
19 



SOME EVIL EFFECTS OF SCHOOL LIFE 385 

Both Hertel and Schmid-Monnard found that the 
percentage of morbidity rises considerably toward the 
end of the school year. Mortality also slightly in- 
creases for a brief period after school entrance; like- 
wise the incidence of infectious diseases. 

The American study of high-school pupils by John- 
son (14) showed that those pupils who were not well 
were generally the ones who studied most, took most 
private instruction, and slept least. 

The most extensive and important single investi- 
gation of this kind yet made is that carried out by 
the Russian Department of Education, the results of 
which were reported by Khlopine in 1911 (iS). This 
investigation was essentially a health census of all the 
secondary schools of the Russian Empire, carefully 
and uniformly carried out under the direction of the 
Chief Medical Officer of Schools. The census was taken 
in 1905-06, and included about 116,000 out of the 
139,000 pupils enrolled in the secondary schools. Its 
main purpose was to establish the incidence for age, 
grade, sex, and type of school of the following defects: 
myopia, spinal curvature, nasal hemorrhages, head- 
aches, and nervous troubles. 

The following chart, which has been constructed 
from the numerous tables given by Khlopine, presents 
a summary of his results in so far as they throw light 
upon the correlation between physical defectiveness 
and the length of school attendance. 

Khlopine's data show that the frequency of myopia 
varies only very slightly according to sex; that it 



386 THE HYGIENE OF THE SCHOOL CHILD 




Grade 
Prep. 



I II in IV 



increases gradually from eastern to western Russia 
and from smaller to larger cities; and that it is higher 

in the technical 
than in the classical 
or modern-language 
schools.^ 

Nasal hemor- 
rhage is caused in 
part by the conges- 
tion of blood about 
the head resulting 
from the forward 
inclination of the 
V VI VII VIII body in reading and 
from the intellec- 
tual and emotional 
tension of school 
life. Nasal hemor- 
rhage is not ordinarily a summation effect from long- 
continued unwholesome conditions. If it does not 
appear in the lower grades it is not likely to appear 
at all. This tends to conceal its dependence upon 
school life: but that this dependence is none the less 
real seems to be demonstrated by the following table 
from Khlopine showing the relative infrequency of 
nose-bleed in the technical schools : — 

1 The influence of the school in the production of myopia is now 
known to be much less than it was formerly believed to be. It is one 
factor, but not the leading one. See chapter xiv. 



FIG. 30 
Showing percentage of certain defects according 
to grade for pupils in the secondary schools of 
Russia. This chart summarizes one of the most 
important investigations of this type. (After 
Khlopine's tables.) 



SOME EVIL EFFECTS OF SCHOOL LIFE 387 

TABLE 37 

Type of School Frequency of nasal 

hemorrhage 

■n y f Classical schools 3.2 per cent 

( Modern-language schools 2.7 

Girls' schools 3.1 

Technical schools 1.7 

This difference in favor of the technical schools 
exists in spite of their excessively heavy program, and 
may be due to the greater amount of physical activity 
which they permit as compared with other schools. 

For spinal curvature, the figures given show an 
increase of only about 50 per cent from the first to the 
sixth grade, but it is by no means clear that 4bis tells 
the whole story. It is possible that but for the unhygi- 
enic postures assumed by the school child the incidence 
of spinal curvature would show a fall at the close of the 
period of accelerated adolescent growth. 

Headaches double in frequency from the first to 
the seventh grade; (other) nervous troubles increase 
nearly fivefold. The significance of these and related 
symptoms has been set forth at some length in chap- 
ters XV to XVIII.- Khlopine seems well justified in con- 
cluding that the school must be conducted in strict 
accordance with the best standards of school hygiene, 
and that its medical service must be improved, if it 
would avoid the danger of injuring the health of its 
pupils. 

That we are not able to marshal as convincing an 
array of incriminating evidence against the schools of 
our own country is due more to the lack of data than 



388 THE HYGIENE OF THE SCHOOL CHILD 

♦ 

to the absence of school injury. As far as evidence is 
available, it points to conditions of morbidity not 
greatly different from those existing in the schools of 
Russia, Germany, Denmark, and Sweden. 

The efects of school life upon growth 

Schmid-Monnard sought to ascertain the influence 
of school life on the body by comparing the growth 
attained during the seventh year of life by children in 
the school with that attained in the same year by chil- 
dren who had not entered school. The results, as 
shown in Table 38, indicate that school entrance brings 
a shock to the nervous system of the young child 
severe enough to retard growth. 



TABLE 38 








Growth in weight — 
expressed in kg. 


Growth in height — 
expressed in cm. 




Boys 


Girls 


Boys 


Girla 


Pupils not attending school 
Pupils attending " 
Difference in favor of former 


2.2 
1.5 

.7 


1.9 
1.6 
1.3 


7.4 
4.2 
3.2 


5.6 
4.5 , 
1.1 



Engelsperger and Ziegler (7) weighed about 500 
children, 5 to 6 years of age, on entering school, and 
again two months later, and found that 20 per cent 
had lost weight. This loss occurred at just that season 
of the year when growth in weight is normally most 
rapid. All should have gained. The retarding effect 
was most marked in the youngest pupils, those under 
6 years of age. The authors conclude that entrance 



SOME EVIL EFFECTS OF SCHOOL LIFE 389 

before 6 years should never be permitted and that 
many pupils ought not to enter school before the age 
of 7 or 8. Quirsfeld (18) followed the growth of 1014 
children through the first four years of school life and 
found that 46 per cent failed to gain weight during the 
entire first school year, while 21 per cent showed an 
actual loss. The number failing to gain during the 
second year was only 10 per cent, the third year 8 per 
cent, and the fourth year about 6 per cent. 

Wretlind's measurements of 3647 children, aged 7 
to 17, showed that the average gain in height for the 
three months of summer vacation ranged from 30 to 
80 per cent as great as that for the entire nine^nonths 
of the school year.^ Whether seasonal influences alone 
were responsible for this difference, or whether a part 
of it was due to the cessation of the school, we do not 
know. 

Binet in France and Schuyten in Belgium sought to 
determine the effect of school life on the child by ascer- 
taining the changes in appetite during the school year. 
The quantity of bread consumed in the daily school 
meal was used as a general index of appetite. On the 
basis of exact records showing the amount consumed 
each day for a school year, both investigators state 
that the consumption of bread diminishes during the 
course of the year, and conclude that intense intel- 
lectual work injures the appetite. 

In another study, Schuyten has attempted to ascer- 
tain by a more direct method the effect of the school 
1 Quoted in reference 17 to chapter in, this book. 



390 THE HYGIENE OF THE SCHOOL CHILD 

upon the child's state of nutrition (22). By use of 
the Oppenheimer formula for determining nutrition/ 
Schuyten made a study of 1100 boys, 3 to 14 years of 
age, and 300 girls, 3 to 6 years of age, for the purpose 
of finding any relation that might exist between the 
state of nutrition and th^e length of school attendance. 
For statistical purposes the pupils were grouped ac- 
cording to age by half-years, 50 in each half-year. 

The results are stated as follows: "The nutrition 
coeflBcient of girls attending the kindergarten drops 
from the third to the sixth year.^ That of the boys 
drops throughout the classes from the third to the 
eighth year, rising again somewhat up to ten years, 
and remaining constant at this lower value up to four- 
teen. . . . The condition of nutrition found at the 
onset, which is excellent, does not return." After 
losing severely in energy of nutrition and assimilation 
up to the eighth year, it appears that the child's body 
partially adapts itself to the new regime. Up to the 
fourteenth year, however, there is inability to reach 
their original excellent condition. 

Effects upon the appetite, nutrition, and the composition 

of the blood 

One of the evils most often blamed for school over- 
pressure is the formal examination. In 1896, Serafani 
discovered that examinations caused a marked reduc- 



1 Girth of arms X 100 

}=ri — ~. — ^-n = nutrition coefficient. 

Chest girth 

2 Girls older than 6 were not examined. ' 



SOME EVIL EFFECTS OF SCHOOL LIFE 391 

tion in the amount of nourishment taken by university 
students, and a corresponding decrease of weight. His 
conclusion was to the effect that prolonged examina- 
tions tend to bring about a condition of the nervous 
system strongly resembling that of neurasthenic per- 
sons. 

Ignatiefl (11) made a study of the physical effects of 
examinations on 242 pupils, 10 to 16 years of age, in a 
Moscow military school. The pupils were weighed just 
before they began preparation for the examinations, 
again at the close of the examinations, and finally after 
the close of the ensuing 3 J months of vacation. Com- 
paring the second weighing with the first, we find that 
79 per cent had lost weight, about 11 per cent had not 
changed, and only 10 per cent had made any gain. 
Since the examination and the preparation for it 
extended over a period of from one to two months, 
and since the pupils were at an age where growth from 
month to month is normally very rapid, all should 
have gained. As it was, those of the lowest grade lost 
on an average 2 per cent of their weight; those of the 
highest classes over 3 per cent. Quite different is the 
result when we compare the third weighing (after 
vacation) with the second (before vacation), for here 
we find loss of weight with only 4.6 per cent and gain 
with 90 per cent. For 13 pupils, the extended vacation 
was not sufficient to make up the loss of weight suf- 
fered during the strenuous pre- vacation period. Igna- 
tieff concludes that in its physical effects, the extended 
examination is comparable to a severe illness, and that 



392 THE HYGIENE OF THE SCHOOL CHILD 

a mental strain severe enough to cause such marked 
alterations in metabolism could hardly fail to affect 
unfavorably that organ most concerned in the over- 
pressure, — the brain itself. 

Koginoff, in a similar experiment, found a loss in 
weight among 75 per cent of the pupils concerned. 
He states that the remaining 25 per cent who were not 
so unfavorably affected were either lazy or of optimistic 
temperament. 

This point deserves emphasis. The child of nervous 
temperament, who worries easily, is extremely liable 
to suffer from overpressure. Worry acts both as cause 
and effect, and fosters a vicious circle of influences. 

Data of this kind lead us to infer that the intensive 
nervous stimulation involved in excessive mental work 
produces its injury through its reflex effects upon the 
nutritional processes and upon sleep. Graziani, how- 
ever, has raised the question whether there may not 
be unfavorable influences more direct than that in- 
volved in this explanation. These he believes are of 
two possible kinds: (1) Imperfect oxygenation of the 
blood and incomplete elimination of carbon dioxide 
due to the superficial respiration which has been proved 
by Mosso, Macdonald, Bush, Obici, and others to 
result from application to mental tasks; and (2) an 
immediate effect upon the chemical composition of the 
blood corpuscles due to the accumulation of fatigue 
toxins resulting from mental work. 

In order to test the latter theory, Graziani subjected 
18 university students and 17 children of 10 to 12 



SOME EVIL EFFECTS OF SCHOOL LIFE 393 

years of age to blood tests before and after the prepar- 
atory period for school examinations. The tests in- 
volved three determinations: the number of red cor- 
puscles, the relative proportion of haemoglobin which 
they contained, and their power of resistance. In 
regard to the number of corpuscles, no constant differ- 
ences were found either with university students or 
children. The proportion of haemoglobin, however, 
showed a decided decrease, amounting to 10 per cent 
with the students, and to 7.4 per cent with the chil- 
dren. The effect upon the power of resistance of the 
red corpuscles was much the same as other investi- 
gators had shown to result from weak J^oisons. 
Graziani, therefore, concludes that intellectual work 
probably produces a toxin which brings about an 
immediate change in the chemical and functional 
properties of the blood. 

To try this theory still further, Graziani subjected 
himself and a 12-year-old boy to the same kind of 
blood examinations, except that in this experiment the 
blood tests were separated only by a number of hours 
of strenuous mental work instead of many weeks, as 
was the case in the earlier experiment. Here, again, 
the decrease of haemoglobin was marked, amounting 
to 7.5 per cent with Graziani himself and to 8 per cent 
with the boy. The experimenter concludes that the 
underlying cause of school anaemia, with its altera- 
tions of metabolism and its imperfect oxygenation of 
the blood, is to be sought in the influence of excessive 
accumulations of toxic products of fatigue. 



394 THE HYGIENE OF THE SCHOOL CHILD 

Another important study of the same type, made by 
Dr. Helwig (9), entirely corroborates the findings of 
Graziani. This author made many blood tests upon 
himself and six other subjects for the purpose of deter- 
mining the influence of school work, fresh air, rest, 
marches, and lessons of different degrees of difficulty, 
both upon the number of red corpuscles and upon their 
"degenerative" and "regenerative" processes. The 
study seems to have been made with the most approved 
technique and with due regard for scientific accuracy. 

The results were rather variable for the corpuscle 
count, but for the *' degenerative " and *' regenerative " 
processes they were strikingly uniform. 

As a result of school work, the "disintegration 
quotient" was increased 29 out of 33 times. The 
author holds that the study "distinctly" demonstrates 
that school work not only imposes a strain upon the 
nervous system, but that it also produces a destructive 
effect on the blood corpuscles. The numerous tables 
presented by the author show the influence of the fol- 
lowing factors upon the condition of the blood: the 
difficulty of the school work, the length of the work 
period, the frequency of the recitation intervals, the 
amount of exercise, and the access to fresh air. 

Helwig concludes that "arduous mental work pro- 
duces unfavorable changes in the blood; that recuper- 
ation is marked by the elimination of waste products 
and by a more or less active regeneration of cor- 
puscles." Observation of the children showed that 
"external manifestations of fatigue invariably accom- 



SOME EVIL EFFECTS OF SCHOOL LIFE 395 

pany the microscopical phenomena associated with 
this state.*' 

It was not only from highly sensitive children that 
reactions were obtained. The author observed the 
same phenomena in his own person after long-con- 
tinued mental strain. ** While a considerable degree 
of corpuscle disintegration could be noted in the morn- 
ing after several weeks of concentrated sedentary work 
indoors, accompanied by physical depression, lassitude, 
and heaviness, this phenomenon disappeared, together 
with the subjective symptoms, after a walk of two 
hours. On another occasion, the disintegration quo- 
tient increased considerably after four hour? inces- 
sant work at the microscope prior to taking food and 
following a prolonged period of close application to 
research work, but decreased rapidly after two hours' 
devotion to a totally different occupation and after 
lunch taken in the open air." Rest days showed an 
immediate effect on the disintegration quotient. Long 
and tiring marches produced only small degenerative 
values and were followed by rapid regeneration. 
During a day of mental work disintegration continu- 
ally increased until late in the afternoon, indicating 
that this part of the day is least suitable for hard 
study. 

The reverse phenomenon, the improvement which 
takes place in the composition of the blood as the result 
of a well-spent summer vacation, has been dealt with 
experimentally by Borchmann (4), who gave blood 
tests to 19 boys and 18 girls of Moscow before a two 



396 THE HYGIENE OF THE SCHOOL CHILD 

months' "summer colony" outing and again after 
their return. The second test revealed an average 
gain of nearly a million red corpuscles per cubic milli- 
meter of blood and a marked increase of haemoglobin. 
This is shown in the following table: — 

TABLE 39 





Boys 


Girls 




Red corpuscles 
per cubic mm. 


Percentage of 
haemoglobin 


Red corpus- 
cles per 
cubic mm. 


Percentage of 
hsemoglobia 


Before vacation 
After vacation 


3,884,000 
4,820,000 


73.1 

79.2 


3,760,000 
4,480,000 


69.6 

78.3 



Borchmann also tested eight of the girls two months 
after their return to school, and found that in three the 
number of red corpuscles had still further increased 
about a quarter-million per cubic millimeter, while in 
the other five there was a decrease of about two thirds 
of a million as compared with the second count. But 
in no case was the condition as unfavorable as before 
the vacation. The haemoglobin had in some cases 
decreased 5 per cent below the second showing; in 
others had increased; but in all cases it surpassed the 
pre-vacation record. Leuch had already secured sim- 
ilar results for children of Geneva, and the work of 
both is strikingly corroborated by blood tests of chil- 
dren who have been transferred from unhygienic 
conditions of the ordinary classroom to the open-air 
school.^ 

* See chapter on open-air schools in Health Work in the Schools, 
by Hoag and Terman. Houghton Mifflin Co. 



SOME EVIL EFFECTS OF SCHOOL LIFE 397 

The efects of school postures on respiration 
The effects of school occupations on the respiration 
have been studied experimentally by Oker-Blom (17) 
and by Badaloni (2). The latter secured kymographic 
records showing variations in the depth of respiration 
in the upper part of the lungs resulting from different 
postures assumed in writing. It was found that the 
asymmetrical position induced an inflexibility of the 
upper part of the chest and caused decreased depth 
of respiration in the upper part of the lowered side. 
Later, Binet raised the question whether this may not 
be compensated by simultaneously increased abdom- 
inal breathing. In a second study, Badaloni^was able 
to prove that no such compensation takes place. His 
records show that the asymmetrical position brings a 
"remarkable decrease" in the expanding capacity of 
the upper chest. The symmetrical sitting posture, 
even when the sternum was allowed to touch the desk, 
showed a less injurious effect. The author concludes 
that the asymmetrical position, even more than the 
sitting posture, per se, is responsible for the school's 
evil effects upon the lungs. He believes that the 
school is in this way an important cause of tubercu- 
losis. 

In 1911, Oker-Blom (17) reports a similar experi- 
mental study of respiration, carried on with 25 pupils 
during different school occupations. The most marked 
difference found was that between standing and sitting. 
The decrease in total respiration for brief sitting (3 
minutes) was about 8 per cent, and for longer periods 



398 THE HYGIENE OF THE SCHOOL CHILD 

(12 to 39 minutes), 50 per cent. Interesting differences 
appeared with different kinds of school work. Knit- 
ting, for example, showed an impeding effect upon the 
respiration of the upper left lung 18 per cent greater 
than did reading aloud. In agreement with the results 
of Badaloni, the greatest impediment to respiration 
was found in the upper part of the lowered side of the 
chest. This, in turn, increases the asymmetrical condi- 
tion and helps to explain why scoliosis sometimes runs 
a progressive course. Oker-Blom concludes that all 
kinds of school activities, including hand-work, should 
be frequently alternated with change of position and 
with physical exercises. 

Psycho-jpathological effects of school life 

There is reason to believe that the intellectual 
apathy of older children and adults is sometimes due 
to school over-dosage or to other kinds of educational 
malpractice. It has often been charged that the school 
has a depressing effect upon the child's spontaneity; 
that it mechanizes his mental processes, and destroys 
the individualistic elements of his personality. 

The depressing and inhibitory effects of school upon 
the child's mind are of such a nature that their ob- 
jective measurement is of course very difficult. An 
attempt at such measurement has been made, however, 
by the Belgian psychologist, Schuyten. The investiga- 
tion in question was undertaken on the assumption 
that the supposed unfavorable influence of the school 
would probably be revealed in the character of the child's 



SOME EVIL EFFECTS OF SCHOOL LIFE 399 



spontaneously controlled drawings. Accordingly, 200 
children of each age (100 boys and 100 girls), from 
3 to 13 years, were asked to make a "drawing of a 
boy." The direction was given orally and without 
explanation or suggestion, everything being left to the 



10 



11 12 13 



Age 

MM 
90 

80 
70 
60 
50 
40 

30 
20 
10 



FIG. 31 

The effect of school entrance on the size of children's spontaneously controlled 

drawings. (After Schuyten.) 

spontaneity of the child. The blank sheets of paper 
and pencils supplied were of uniform size and material. 
The drawings thus secured were measured in length and 
width for the purpose of ascertaining age differences. 
The results are embodied in the accompanying figure. 
It is seen that the child's entrance into the school 



















Av 


y 


/ 










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Li 


NGTH 










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WIDTH 


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400 THE HYGIENE OF THE SCHOOL CHILD 

brings an almost immediate decrease in the size of his 
spontaneous drawings; that the pre-school norm for 
width of drawing is not again reached by either boys 
or girls, and that the pre-school norm for height is 
reached only after two and a half years. Schuyten 
claims to have found also a corresponding deterio- 
ration in the quality of the drawings as judged by 
aesthetic standards. 

The explanation, in the opinion of Schuyten, is as 
follows. The child in the kindergarten is free, active, 
and unburdened by care. At six he is precipitated into 
the routine and serious work of the school entirely 
without transition or preparation. Here not only is 
play prohibited, but almost every kind and degree of 
physical activity as well. He is governed by unreason- 
ing notions of severity. Not being permitted to see, 
hear, speak, or move, except within certain narrow 
and arbitrary limits, his "dilatation" ceases, his per- 
sonality undergoes a general recoil, and the dynamo- 
genie effects of gayety are lost (21). In some cases the 
fear "complex" develops. 

Whatever we may think of the validity of Schuy- 
ten's simple experiments, the fact that the school does 
not always develop self-reliance and the power of inde- 
pendent thinking is conceded by every one. How to 
carry on the routine work of the school without dead- 
ening the native intellectual interests and curbing 
overmuch the child's personality is a problem whose 
solution must be sought anew by every generation of 
teachers. 



SOME EVIL EFFECTS OF SCHOOL LIFE 401 



The annual accumulation of fatigue 
Several investigations indicate that mental fatigue 
accumulates during the school year. Schuyten, for 
example, conducted for an entire school year a series 
of fatigue tests by means of the esthesiometer upon 
11 boys and 10 girls, m m 
The tests were given 
daily during the first 
week of each school 
month and the re- 
sults for the differ- 
ent months were 
then compared. 
Preliminary tests to 
accustom the chil- 
dren to the experi- 
ment had been given 
for two months at 
the close of the pre- 
vious school year. 
The accompanying 
curves show the average month by month decrease in 
sensitivity of the skin of boys and girls for the second 
year. 

In another series of experiments Schuyten gathered 
important evidence of the deterioration which the 
voluntary attention of children undergoes under vari- 
ous influences. His attention test, which consisted of 
a five-minute reading lesson, was given four times daily 
(at 8 and 11 o'clock in the morning and at 2 and 4 in 



20 
19 
18 
17 
16 
15 
14 

13 
12 
11 

^^123456 78 9 10 
Month of School Year 

FIG. 32 
The annual curve of fatigue in school children as 
measured by the esthesiometer. Greater ver- 
tical distance means decreased sensitivity of the 
skin. The two vertical dotted lines represent 
brief vacations. Note their effect on curves. 
(After Schuyten.) 











^'' 


,--\ 






/ 










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/ 

■.^z 








4 


/' ■> 






r' 


-\ 




r 


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/ 
/ 






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f 


1 


V 






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1 
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402 THE HYGIENE OF THE SCHOOL CHILD 



i. 



the afternoon), for an entire school year to the pupils 
of 16 classes. Besides demonstrating a decline of 
attention from 8 to 11 in the forenoon and from 2 to 4 
in the afternoon, the results, as graphically represented 
in the following curve, demonstrate an astonishing 
decline in the power of attention toward the end of the 
school year. 

A part of this decrease in the power of voluntary 
effort may, of course, be due to the influence of the 

higher tempera- 

Oct.Nov. Dec.Jan. Feb.Mch.Apr.May.Tttne July turC of thc SDrinff 

and summer 
months. This is 
indicated by the 
upward slope of 
the curve during 
the autumn. At 
the same time, in 
the light of sup- 
plementary evi- 
dence from other fatigue studies, it would be unreason- 
able to explain the curve entirely on the temperature 
theory. Lobsien, in a lengthy series of memory tests, 
has found a similar decline in the memory ability 
of children during the school year. 

It is well to emphasize that inattention is more than 
a mere index of mental eflSciency. Its function is also 
a positive one; it is a protective agency, designed to 
conserve the deeper levels of energy from too complete 
exhaustion. It is a beautiful and necessary adaptation 



t>u 






J 


^ 


\ 












bb 






/ 








\ 








50 
45 




y 












\ 






















\ 




40 
35 




















\ 























FIG. 33 

Showing curve of mental fatigue during the school 
year as measured by Schuyten's attention test. 
Vertical distance represents the percentage of chil- 
dren, whose attention did not fail during the test. 



SOME EVIL EFFECTS OF SCHOOL LIFE 403 

of nature that the psychophysical organism accumu- 
lates stores of energy which it refuses to draw upon 
except under the greatest provocation and at moments 
of unusual stress. This is the factor of safety, which it 
is the function of sleep, inattention, and other rest 
states to conserve. Inattention is, therefore, an indis- 
pensable factor in mental economy — not a moral 
fault, but a safety-valve. Teachers should learn to 
respect it.^ Kraepelin has even suggested that "poor 
teachers are a hygienic necessity"; that highly inter- 
esting instruction continued for six or seven hours 
a day would inevitably bring about a condition 
of fatigue in excess of the limits of safety. 

Disturbance of the motor functions is one of the 
common symptoms of nervous exhaustion. Toward 
the end of the school year automatisms increase in 
number, the liability to chorea increases, postures 
become more faulty, loss of tone in the ciliary muscle 
makes "latent" hyperopia or "latent" astigmatism 
"manifest." The loss of muscular tone is especially 
evident in the aggravation of speech defects. (See 
chapter xx.) 

Without doubt, the evil effects of school life would 
be more often observable were it not for the plasticity 
of growth which enables children, like the guinea pigs 
in the experiment of Professor Minot, to repair many 
kinds of physical damage. Nevertheless, in spite of 

1 In Triplett's study of The Faults of Children, "inattention" 
headed the list in the frequency with which it was named by teachers 
as the "greatest fault of children." 



404 THE HYGIENE OF THE SCHOOL CHILD 

the child's wonderful power of rebound, we have found 
unmistakable evidence of the injurious effects of the 
school. The close correlation of morbidity with years of 
school attendance^ with length of daily program, and with 
the progression of the school term ; the deterioration of at- 
tention toward the end of the school year ; the damaging 
effects of strenuous school activities upon appetite, diges- 
tion, metabolism, and the constitution of the blood ; the ill 
effects of deprivation from fresh air and from healthful 
physical exercise; the impairment of nervous coordina- 
tions and the profound disturbances rejlexly produced by 
worry — these and other injurious effects have been suffi- 
ciently attested to justify the most vigorous prosecution of 
reform in matters of educational hygiene. 

Some of the worst consequences are either deferred, 
or else are of such intangible character that they are 
not apparent to common observation. In the former 
class belong the sedentary habits instilled by the many 
years of school life. These remain with most of us as 
an unclosed debit account, exacting throughout life a 
progressively usurious toll of health and happiness. 

It is not claimed, of course, that school life is detri- 
mental to the health of all children. Fortunately the 
exuberance of vitality is so marked a characteristic of 
childhood and youth that many escape without having 
suffered observable injury. It is the child of somewhat 
less than normal resistance who breaks under the 
pressure. 

Nor are the evils which do exist beyond remedy. 
There is no reason why the school should not be as 



SOME EVIL EFFECTS OF SCHOOL LIFE 405 

healthful in its influence upon both body and mind as 
the most perfectly ordered home. Until it approxi- 
mates this ideal, the campaign for school reform should 
continue. 

By proper attention to schoolhouse construction, 
and to heating, lighting, ventilation, and sanitation; 
by the multiplication of open-air schools; by a thor- 
ough and universal system of medical supervision; by 
reducing seat work to a minimum so as to give more 
time for manual activities and play; by completely 
eliminating home study below the high school and by 
rigidly limiting it to one or two hours thereafter; by 
observing the laws of fatigue in the school day; by the 
substitution of freedom for the atmosphere of repres- 
sion; by making the cultivation of physical and mental 
health as much its aim as the imparting of knowledge, 
the school can avoid all the injuries we have men- 
tioned, and others. Until all of these reforms have 
become general, the school will continue to mingle 
evil with the good it accomplishes. 

Types of children who are sometimes injured hy the work or 
environment of the school 

1. Children who are poorly fed. 

2. Anaemic children. 

3. Those with chronic indigestion. 

4. Children with tendency to constipation. 

5. Children with tubercular tendencies. 

6. Children with obstructed nasal breathing. 

7. Children whose muscular development is weak. 

8. Children whose vision is defective. 



406 THE HYGIENE OF THE SCHOOL CHILD 

9. Children with much outside work to do. 

10. Children of unusual talent in some line. (Talent crushed 
by pressure of other work.) 

11. Children of general mental superiority. (Held back by 
the lock-step of the school.) 

12. Children of sub-normal mental endowment. (Dis- 
heartened by failure and repetition of work.) 

13. Normal children whose development is merely belated. 

14. Nervous children, including : — 
(a) those with tendency to chorea; 
(6) those who stutter; 

(c) those who suffer disturbed sleep; 

(d) those subject to headaches; 

(e) those who are abnormally timid; 

(J) those who are oversensitive to praise or blame; 

(g) those of neurasthenic tendency; 

{h) the morbidly precocious; 

(i) children who are over-imaginative and need the 

corrective furnished by contact with things rather than 

with books. 

REFERENCES 

1. Dr. A. Albu: "Der Antheil der Schule an den Storungen der 
Entwl. u. Ernahrung der Kinder." Zt.f. Pad. Psych., 1908, pp. 
243-55. 
*2. Giuseppe Badaloni: "Encore du travail a I'ecole en rapport a 
la fonction de la respiration." Inter. Mag. Sch. Hyg., 1910, vol. 
VI, pp. 153-65; also in vol. ii, 1906. 

3. A. Binet: "La consommation du pain pendant une annee 
scolaire." V Annee Psychologique, vol. iv, p. 337 jf. 

4. Borchmann: Ueber den Einfluss der Fereinkolonien avf der 
Beschaffenheit des Blutes des Kindes. Reviewed in Zt.j. Schulges., 
1899, pp. 320-23. 

5. Victor Bridon: "Le r61e de la gaiete dans I'education." Inter. 
Mag. Sch. Hyg., vol. i, pp. 159-70. 

*6. Dr. Clement Duke: Needless Injury to Children. London, 

1899, pp. 37. 
*7. A. Engelsperger u. O. Ziegler: "Beitr. zur Kentniss der physi- 

schen u. psychischen Natur des sechsjahrigen in die Schule 

eintretenden Kindes." Zt.f. Exp. Pad., vol. i, pp. 173-235, and 

vol. II, pp. 49-95. 



SOME EVIL EFFECTS OF SCHOOL LIFE 407 

*8. Dr. A. Graziani: "Einfluss der uberinassigen Geistesarbeit auf 
d. Zahl, Hamoglobingehalt u. auf den Widerstand der roten 
Blutkorperchen." Zt. f. Schulges., 1907, pp. 337-53 (bibliog- 
raphy). 

*9. Dr. Helwig: "Neuere Untersuchungen iiber d. Wirkung des 
Unterrichts auf den kindlichen Korper." Inter. Mag. Sch. Hyg., 
1911, pp. 218-24. 
*10. Hertel: Overpressure in the High Schools of Denmark. London, 
1885, pp. 44 + 148. 

11. Ignatieff: Der Einfluss der Examina auf das Korpergewicht. 
Reviewed in Zt. f. Schulges., 1898, p. 244. 

12. Mile. loteyko: "Le surmenage scolaire." Rev. Psych., 1910, 
pp. 265-97. 

*13. G. W. Khlopine: "Les maladies scolaire parmi les eleves des 
etablissements d'enseignement moyen russes." Inter. Mag. 
Sch. Hyg., 1911, pp. 280-91, and 329-68. 

14. N. C. Johnson: "Habits of Work, etc., of High-School Pupils 
in Indiana." Sch. Rev., 1899, pp. 257-77. 

15. Arthur MacDonald : " Einfluss der Gehirnarbeit auf die Atmung 
der Schiller." Zt. f. Schulges., 1896, p. 539. ^ 

16. Albert Mathieu: "La question du surmenage scolaire." Inter. 
Mag. Sch. Hyg., vol. iv, 1908, pp. 419-31. 

*17. Max Oker-Blom: "Ueber d. Einfluss verschiedenartiger Schul- 

beschaftigung auf d. Ventilation der oberen Lungenteile." 

Inter. Mag. Sch. Hyg., 1911, pp. 369-405. 
*18. Dr. E. Quirsfeld: "Zur physichen u. geistigen Entwl. des 

Kindes wahrend der ersten Schuljahre." Zt.f. Schulges., 1905, 

pp. 127-85. 
*19. Dr. Karl Schmid-Monnard: "Die chronische Kranklichkeit in 

unseren mittleren u, hoheren Schulen." Zt. f. Schulges., 1897, 

pp. 593-615, and 666-85. 
20. Dr. M. Schuyten: "Qu'est-ce-que le surmenage.?" Rev. Psych., 

1908, vol. I, pp. 143-57. 
*21. Dr. M. Schuyten: L'Sducation de la femme. 1908, pp. 458. 

(Chapter ii, "Influences psychique immediates de I'ecole," 

pp. 177-88. See also chapter iii, "La fatigue intellectuelle.") 
22. Dr. M. Schuyten: "Rapport sur I'inattention; ses causes, ses 

remedes." Inter. Mag. Sch. Hyg., 1910, pp. 503-09. 
*23. Dr. M. Schuyten: The Nutrition Coefficient of Antwerp School 

Children. Summary by the author, in School Hygiene, 1913, pp. 

51-53. 
(For further statistics on the prevalence of defects see other chap- 
ters in this volume; also the periodicals and all standard texts on 
school hygiene.) 



SUGGESTIONS 

FOR A TEACHER'S PRIVATE LIBRARY ON 

THE HYGIENE OF PHYSICAL AND 

MENTAL GROWTH. 

*1. Jessie H. Bancroft: The Posture of School Children. 

1913, pp. 327, $1.50. Macmillan Co., N.Y. 
2. Louise Stevens Bryant: School Feeding. 1913, pp. 

345, $1.50. Lippincott Co., Phil. 
*3. W. S. Cornell: The Health and Medical Inspection of 

School Children. 1912, pp. 614, $3.00. F. A. Davis Co., 

Phil. 
*4. F. B. Dressler: School Hygiene. 1913, pp. 369, $1.25. 

Macmillan Co., N.Y. 

5. David Forsyth: Children in Health and Disease. 1909, 
pp. 362, $3.00. P. Blakiston's Son & Co., Phil. 

6. Sir John E. Gorst: The Children of the Nation. 1907, 
pp. 297, $1.75. Methuen & Co., London, Eng. 

7. Leonard G. Guthrie: Functional Nervous Disorders in 
Childhood. 1909, pp. 300, $2.50. Oxford University 
Press, London, Eng. 

*8. E. B. Hoag: The Health Index of Children. 1910, pp. 
188, $.80. Whitaker & Ray-Wiggin Co., San Fran- 
cisco. 

*9. E. B. Hoag and Lewis M. Terman: Health Work 
in the Schools. Houghton Mifflin Co., Boston. 

10. R. Tait McKenzie: Exercise in Education and Medi- 
cine. 1910, pp. 393, $3.00. W. B. Saunders Co., Phil. 

11. George B. Mangold: Child Problems. 1910, pp. 352, 
$1.50. Macmillan Co., N.Y. 

*12. Albert Moll: The Sexual Life of the Child. 1912, pp. 

339, $1.50. Macmillan Co., N.Y. 
*13. Nathan Oppenheim: The Development of the Child. 

1910, pp. 296, $1.25. Macmillan Co., N.Y. 



A TEACHER'S PRIVATE LIBRARY 409 

14. G. E. Partridge: The Nervous Life. 1911, pp. 216 

$1.00. Sturgis & Walton Co., N.Y. 
*15. Walter Pyle: Personal Hygiene. 1910, pp. 472, $1.50 

W. B. Saunders Co., Phil. 
16. Stuart H. Rowe: The Physical Nature of the Child 

1899, pp. 207, $1.00. Maemillan Co., N.Y. 
*17. E. W. Scripture: Stuttering and Lisping. 1912, pp 

251, $1.50. Maemillan Co., N.Y. 
18. John Spargo: The Bitter Cry of the Children. 1909, pp 

337, $1.50. Maemillan Co., N.Y. 
*19. J. M. Tyler: Growth and Education. 1907, pp. 294 

$1.50. Houghton Mifflin Co., Boston.^ 

^ The books in the above list which are most likely to be of im- 
mediate help to the teacher are marked with a *. 



GLOSSARY 



aerate, to supply with air. 

alveolar abscess, "ulcerated 
tooth," or "gum boil." 

ambidextrous, having the abil- 
ity to use both hands with 
equal ease. 

ametropia, any kind of abnor- 
mal refraction of the eye. 

anaemia, deficiency of blood, or 
of red corpuscles. 

anthropology, the science of 
man. 

anthropometry, a branch of an- 
thropology which is con- 
cerned with the measurement 
of the human body. 

aprosexia, inability to give at- 
tention. 

astigmatism, a refractive error 
of vision due to unequal 
curvature of the parts of the 
eye. 

asymmetry, want of symmetry 
or proportion. 

atrophy, the wasting or wither- 
ing of an organ or part of the 
body. 

bacteriology, the department 
of zoology which deals with 
bacteria. 

biennium, a period of two 
years. 

binocular vision, the function- 
ing of both eyes together in 
vision. 



carious, decayed. 

chorea, "St. Vitus's Dance." 

choreiform, resembling cho- 
rea. 

cretinism, a form of feeble- 
mindedness due to defect of 
the thyroid giand. 

dementia prsecox, a form of in- 
sanity which usually has its 
onset between the age of fif- 
teen and forty years. 

dendrites, the tree-like branch- 
es of nerve fibers extending 
from the nerve-cell. 

dental caries, decay of the 
teeth. 

dentine, the calcified substance 
that forms the main part of 
the tooth. 

diathesis, a predisposition to 
certain forms of disease, as 
"a tubercular diathesis." 

dynamogenic, tending to pro- 
duce increased nervous ac- 
tivity. 

enmietropia, the condition of 
the eye in which refraction 
is perfect. 

eugenics, the science of im- 
proving the human race 
through application of the 
laws of heredity. 

euthenics, the science of im- 
proving the human race 



GLOSSARY 



411 



through the control of en- 
vironment. 

habit-spasm, an aimless and 
stereotyped twitching or 
contraction of one or more 
muscles of the body. 

haematology, that branch of 
medical science which treats 
of the blood. 

haemoglobin, that part of the 
red corpuscles whose func- 
tion is to carry oxygen. 

Holmgren test, a test of color 
vision by use of the Holm- 
gren worsteds. 

hyperopia, "far sight." 

hypertrophied, abnormally en- 
larged. 

inhibition, the act of restrain- 
ing or repressing, as to check 
a nervous or mental process. 

kyphosis, backward curvature 
of the spine. 

laryngitis, an inflammation of 

the mucous membrane of the 

larynx, 
lisping, an imperfect utterance, 

like the substitution of th for 

s or z. 
lordosis, forward curvature of 

the spine, 
lymphatic, pertaining to the 

lymph. 

mastoid, that part of the tem- 
poral bone situated directly 
behind the ear. 

medullation, the growth of 
sheath covering the nerve 



fibers of the central nervous 
system. 

" mental complex," an asso- 
ciated group of ideas sub- 
merged below the level of 
consciousness and producing 
pathological mental condi- 
tions. 

metabolism, the building-up 
and tearing-down processes 
of living material. 

migraine, a special form of 
headache. 

morbidity, imperfect state of 
health. 

moron, that grade of feeble- 
mindedness just below nor- 
mality. 

myope, a near-sighteA person. 

myopia, near sight. 

neurasthenia, a chronic state of 
nervous exhaustion. 

neuroglia, the supporting tis- 
sue of the central nervous 
system. 

neurosis, a nervous disorder. 

neurotic, predisposed to nerv- 
ous disorders. 

obsession, a fixed idea; an idea 
that persists in spite of ef- 
fort to banish it. 

oculist, a person skilled in 
treating diseases of the eye. 

optician, one who makes or 
deals in optical instruments 
or glasses. 

oral hygiene, the hygiene of the 
mouth. 

orthodontia, mechanical treat- 
ment for correcting irregu- 
larity of the teeth. 



412 



GLOSSARY 



orthopsedia, 
prevention 
the body. 

orthophonia, 
prevention 

otitis media, 
the middle 

oxygenation, 
oxygen. 



the correction or 
of deformity of 

the correction or 
of speech defects, 
acute infection of 
ear. 
supplying with 



pathogenic, productive of dis- 
ease. 

pharyngitis, injflammation of 
the mucous membrane of the 
pharynx. 

phobia, a morbid fear. 

phonation, vocal utterance. 

phylogenetic, pertaining to the 
history of the evolution of 
the species. 

prophylaxis, preventive treat- 
ment for disease. 

psychiatry, the branch of medi- 
cine that relates to mental 
disease. 

psychoanalysis, a method of 
treating functional mental 
disorders. 

psychotherapeutics, the treat- 
ment of mental disorders in 
general. 

radiograph, an X-ray picture, 
rickets, a nutritional disease of 

childhood affecting chiefly 

the bones. 



scoliosis, lateral curvature of 
the spine. 

septic, productive of putrefac- 
tion through the action of 
bacteria. 

sinistrality, left-handedness. 

sinus, a slender opening or 
cavity. 

strabismus, cross-eyedness. 

tartar, a yellowish incrustation 
that forms on the teeth. 

therapeutics, the treatment of 
disease. 

tic, a spasmodic twitching of 
muscles, especially of the 
face. 

toxaemia, a poisoned condition 
of the blood. 

toxin, a poisonous compound 
of animal, bacterial, or vege- 
table origin. 

triennium, a three-year pe- 
riod. 

unidextrous, having greater 
skill in one hand than in the 
other. 

vasomotor, producing contrac- 
tion or dilatation of the 
walls of vessels; as the blood 
vessels of the skin. 

vertigo, dizziness. 

vital capacity, the ratio of lung 
capacity to weight. 



INDEX 



AoENoros, 136, 207 jf.; causes of, 
215; effects on mental and 
physical development, 210 jf.; 
signs of, 216. 

Alcohol and growth, 45. 

Allport, Dr. F., 216 #. 

Appelt, Dr., 355. 

Arkle, Dr., 102. 

Astigmatism, 260 J". 

Ayres, L., 210. 

Badaloni, Dr., 397. 

Ballard, P. B., 345/. 

Baths, 143. 

Bauer, Dr., 265 /. 

Bell, S., 123. 

Bernhard, Dr., 365. 

Binet, A., 389. 

Biological perspective, 13. 

Blood, and resistance to disease, 
48 ; effects of school work 
upon, 390/.; of ill-nourished 
children, 112; relation to res- 
piration, 151 ff. 

Boas, F., 22. 

Bobbitt, J. F., 33. 

Book, Dr. W. F., 322. 

Books, hygiene of, 276 /. 

Borchmann, Dr., 395. 

Brown, Dr., 175. 

Bullock, N. K., 212, 213/ 

Buriiham, Dr. W., 15, 303 / 

Butterworth, Dr., 264, 

Canavan, Dr., 73. 

Chorea, and rheumatism, 310. 

Circulatory system, growth of, 

48. 
Claparede, Dr. E., 363, 364. 
Clinics, school clinics, 376. 
Coffee, effects on sleep, 376. 
Color-blindness, 272. 



Colyer, Dr., 180. 
Conradi, E., 336 /. 
Conservation, 1/, 6/ 
Cornell, Dr., 212, 228, 268. 
Crampton, C. W., 64 / 
Crippled children, education of, 

91/ 
Cross-eye, 263 / 
Crowley, Dr., 101. 

Deaf children, special schools for, 
239/ 

Deafness, prevention M, 233. 

De Busk, B. W., 51. 

Defects, percentages of, 8; statis- 
tics of , 383/ 

Dental, clinics, 192; hygiene, 
167/ 

Desks, 81 / 

Digestive system, growth of, 50. 

Discipline, and nervousness, 324. 

Drafts, 160/ 

Duke, Dr. C, 363, 364, 367, 369. 

Ears, 221 /.; causes of defects, 

228/; discharging ears, 227; 

signs of defects, 243. 
Engelsperger, Dr., 388. 
Environment and growth, 38. 
Epileptics, 316/ 
Ernst, Dr., 183, 189. 
Eugenics, 34. 
Euthenics, 35. 
Examinations, effects of school 

examinations, 391 / 
Eye, 245/; eye-strain, 248/, 

264/; squint, 263/ 

Fatigue, during school year, 401 

Fears, morbid fears, 321 /. 
Feeble-mindedness, 15; growth 



414 



INDEX 



of feeble-minded children, 28; 
relation to eugenics, 34. 

Feeding, dietaries, 107; inade- 
quate, 104/. 

Fisher, Irving, 4. 

Flat-foot, 87/. 

Food habits, 123. 

Fraenkel, Dr., 133. 

Freud, Dr. S., 320/., 355. 

Gibson, Dr., 175. 

Goddard, H. H., 28, 371. 

Gould, Dr. G. M., 251. 

Grancher, Dr., 133. 

Graziana, Dr., 392/ 

Growth, 20/; and scholarship, 
66; circulatory system, 48; 
digestive system, 50; disease, 
26; disorders of, 72/; effects 
of school upon, 44, 388 / ; fac- 
tors influencing, 32; glandular 
influence on, 42; influence of 
alcohol on, 45; irregularity of, 
59; muscular system, 52; nerv- 
ous system, 57; oscillations, 
25; percentile, 24; physiological 
development, 47; prenatal in- 
fluence on, 45 ; relation be- 
tween physical and mental, 27; 
respiratory system, 51; retard- 
ation, 29; rhythms, 43 ; sex dif- 
ferences, 22/, 63; skeletal sys- 
tem, 56 ; social influences, 36/ 

Gulick, L. T., 141. 

Gutzmann, Dr. A., 351. 

Hall, G. S., 60. 

Hamburger, Dr., 132. 

Harrington, Dr., 104. 

Headaches, 282 / ; and eye- 
strain, 268; causes of, 283; fre- 
quency of, 282; prevention of, 
287. 

Healy, Dr. R., 317. 

Hearing, causes of defects, 228 
/.; defects of, 221/.; impor- 
tance for mental development, 
223/ ; methods of testing, 237; 
prevention of defects, 233; sta- 
tistics of defects, 221 /. ^ 



Height, 22. 
Helwig, Dr., 394/ 
Henneberg, Dr., 181. 
Heredity, 32; and dental defects, 

190; and myopia, 259; and 

speech defects, 342; and visual 

defects, 259/ 
Hertel, Dr., 364, 382. 
High-school pupils, growth of, 

65. 
Hill, Leonard, 158. 
Hoag, Dr. E. B., 105, 206, 209, 

228, 252, 263, 267, 282, 376. 
Hoch, Dr., 308. 

Hocking, Adeline, 362, 366, 368. 
Hodge, C. F., 46. 
Hoesch-Ernst, Lucy, 39. 
Hollingsworth, H. L., 376. 
Holmes, A., 177. 
Hoist, Dr., 283. 
Home study, in relation to sleep, 

377. 
Hookworm disease, 41. 
Hudson-Makuen, Dr., 335, 352. 
Huey, Dr. E. B., 277, 289, 344. 
Humidity, 155/ 
Hutchinson, Dr. W., 284. 
Hygiene instruction, 140. 
Hyperopia, 248, 253/ 

Ignatieff, Dr., 391. 
Insanity, 289. 

James, W., 326. 
Janet, P., 299. 
Jessen, Dr. E., 167, 170. 
Johnson, G. E., 171. 

Kafemann, Dr., 208/ 
Kelynack, Dr. T. N., 134. 
Kemsies, Dr., 84. 
Khlopine, Dr., 385 /. 
Kirchner, Dr., 129/ 
Kobrak, Dr., 225/ 
Kraepelin, Dr. E., 403. 
Kyphosis, 75/ 

Left-handedness, 55, 345. 
Liebmann, Dr., 354. 
Lindley, E. H., 315. 



INDEX 



415 



Lobsien, Dr., 402. 

Lordoses, 77. 

Love, Dr., 240 /. 

Lunches, school lunches, 105. 

Mackenzie, W. T., 39. 
MacMillan, D. P. (and Bodine), 
100. 

Magelssen, 283. 

MaUing-Hanson, 43, 68. 

Malnutrition, 98 ff. {see also Nu- 
trition); amount of, 99; and 
dental defects, 188 Jf.; causes 
of, 104 j^.; evils of, 98; symp- 
toms of, 108/. 

Manaceine, Dr. M., 364. 

Mastication, 174; and dental de- 
fects, 174. 

Maturity, anatomical, 14; physi- 
ological, 14. 

McCallie, Dr., 271. 

Measles, 48. 

MeduUation, of nerve fibers, 
57/. 

Mental hygiene, 289 /., 299 #., 
318/. 

Metabolism, 50, 108. 

Meyer, Dr. A., 307 /. 

Michael, Dr., 188. 

Migraine, 286. 

Morbidity, 14. 

Mortality, 14. 

Mouth, breathing, 201; hygiene, 
191. 

Muscular system, growth of, 
52. 

Myopia, 249, 255 /. — 

Nasal hemorrhage, 386. 

Nervousness, and chorea, 310/.; 
and headaches, 285 ; and moral 
disorders, 317; and shock, 238; 
and stuttering, 355; and sui- 
cides, 329 /.; dementia prse- 
cox, 306; description of a nerv- 
ous child, 289 /.; education 
of nervous children, 318 /.; 
hysteria, 302; in relation to 
defective teeth, 177; morbid 
fears, 321/.; preventive men- 



tal hygiene, 289/., 299/., 318 
/.; psychasthenia, 299 /.; 
school epidemics, 303 /. ; sug- 
gestions for observation, 297 
/. ; symptoms, 289 /. ; tics and 
habit-spasms, 313/. 

Nervous system, growth of, 57. 

Netschajeff, Dr., 370. 

Newmayer, Dr., 224. 

Night terrors, 377. 

Nose and throat, as related to 
hearing, 299. 

Nose, hygiene of, 197/.; relation 
to health, 197/. 

Nutrition, 39 /. {see also Malnu- 
trition) ; effects of school upon, 
390/.; effects on teeth, 188; 
physiological factors, 123. 

Oker-Blom, Dr. M., 397. 

Oltuszewski, 341. % 

Open-air schools, 165; effects on 

nutrition, 120. 
Oppenheimer, 111. 
Oral hygiene, 167/. 
Orthodontia, 193. 
Osier, Dr. Wm., 167. 
Over-pressure, 381 /. 

Paul, Dr., 158. 

Pearson, K., 34. 

Pedley, Dr., 169, 176, 183/. 

Phillips, Dr., 130. 

Physical education, 17. 

"Physiological age," 61/. 

Physiological development, 47. 

Pigeon-breast, 86. 

Playgrounds, 143. 

Pollak, Dr., 135. 

Porter, W. T., 27/. 

Posture, hygiene of, 72/. 

Precocity, 29. 

Preventable diseases, cost of, 3/. 

Psychic epilepsy, 316. 

Quirsfeld, Dr., 389. 

Ravenhill, Alice, 367, 374. 
Respiration, 150 /.; effects of 
school upon, 397/. 



416 



INDEX 



Respiratory system, growth of, 
51. 

Retardation, and defective hear- 
ing, 223^.; and malnutrition, 
100; and sleep, 369/.; effects 
of adenoids on, 210 ; effects of 
defective teeth on, 179. 

Rheumatism, and chorea, 310; 
and tonsils, 204. 

Richards, Mrs. E., 119. 

Rickets, 79 /. 

Right-handedness, 55, 345. 

Rose, Dr., 189. 

Rotch, T. M., 62/., 27. 

Roth, Dr., 75. 

Rothfeld, Dr., 86. 

Rouma, G., 339, 347. . 

Round shoulders, 75. 

Rubner, Max, 120. 

Schmid-Monnard, Dr., 383 /., 
388. 

School, and fatigue, 401 ff.; as 
a cause of morbidity, 383 ff.; 
clinics, 144; effects on respira- 
tion, 397; effects upon growth, 
388 ff. ; effects upon nutrition, 
390/.; evils produced by, 381 
/.; physician, 9; psychopatho- 
logical effects, 398/ 

Schuyten, Dr., Ill, 389/., 398/ 

Scoliosis, 77. 

Scripture, E. W., 335, 351, 356. 

Shock, 328. 

Sidis, Dr. B., 326. 

Skeletal system, growth of, 56. 

Sleep, 362/; amount needed, 363 
/. ; amount secured, 364 / ; 
and nervousness, 376 ; condi- 
tions of, 372 / ; relation to 
intelligence, 369/ ; suggestions 
for a sleep survey, 378, 

Special schools, for children with 
defective vision, 275; for deaf 
children, 239 /; for nervous 
children, 330 ; for stuttering 
children, 347 / ; orthopedic 
classes, 85. 

Speech defects, 335/.; frequency 
of, 336/; lisping, 338/; stut- 



tering, 335, 340/.; stiggestions 
for observing, 360. ^^^ 

Spinal curvature, 73 /; causes 
of, 79/.; injuries produced by, 
78; treatment of, 84/. 

Squint, 263/. 

Squire, Dr., 123. 

Still, Dr., 261. 

Stockard, C. P., 45. 

Stuttering, 335/, 340/; causes 
of, 341; prevention of, 357/; 
treatment of, 347 /, 351. 

Suicides, of children, 329/. 

Teeth, 167/; causes of decay of, 
183 /; cleanliness of, 186; 
defective teeth and growth, 
180; defective teeth and men- 
tal development, 178; import- 
ance of temporary set, 188 ; 
injuries produced by defective 
teeth, 173; orthodontia, 193; 
prevention of decay, 191; sta- 
tistics of defects, 169/; ulcer- 
ated teeth, 155 ff. 

Temperature, 155 ff. 

Terman, L. M., 40, 137, 144, 330, 
368, 396. 

Throat, hygiene of, 197/. 

Tonsils, 202/; and rheumatism, 
204; diseased tonsils, 202/ 

Tonzig, Dr., 117. 

Triplett, N., 403. 

Tuberculosis, 127/; in children, 
129; of the bone, 136; pre- 
vention of, 137/; ravages of, 
127/ 

Underwood, Dr., 189. 

Vacation colonies, 140. 

Ventilation, 148/; and air cur^ 
rents, 155; and humidity, 155 
/; and temperature; 155; of 
bedrooms, 373. 

Vision, 245/.; directions for test- 
ing, 269 /.; frequency of de- 
fects of, 251/.; mechanism of, 
247/ 

Vital capacity, 51. 



INDEX 



417 



Vocational guidance, 140, 278. 
Voice, hygiene of, 335 ff. 
Von Pirquet, Dr., 132. 

Wallace, Dr. S., 186. 
Wallin, J. E., 179. 
Ward, Mrs. H., 91. 
Weight, 23. 



Weygandt, Dr., 370. 
Williams, Dr. T., 301. 
Wimmenauer, Dr., 102, 111; 
Wingerath, Dr., 257. 
Work, wholesome effects of, 327, 

Yearsley, Dr., 209, 212, 239. 
Young, Dr., 136. 



\J 



